Stanford Children’s Health Otolaryngology/Head and Neck Surgery Program

Pediatric Otolaryngology Head and Neck Surgery (ENT)

Pediatric Otolaryngology

Table of Contents Stanford Children’s Health Otolaryngology/Head and Neck Surgery Program The benefits of specialization and coordinated whole-patient care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Stanford Advantage Research fuels clinical success . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 New Hospital/New ORs One of the nation’s most technologically advanced, sustainable hospitals . . . . . . . . . . . . . . . . . . . . . . . . . 7 Aerodigestive and Airway Reconstruction Coordinated care for complex conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Cleft and Craniofacial Center Experts in all types of craniofacial abnormalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Patient Story Coordinated care helps 4-year-old Jack thrive. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Microtia and Ear Canal Atresia Clinic Internationally recognized treatment, education, and research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Children’s Thyroid Center Compassionate, coordinated care for children with thyroid conditions . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Children’s Hearing Center: Audiology Helping children to hear and communicate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Vascular Anomalies Accurate diagnosis and comprehensive interdisciplinary care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Complex Sleep Disorders Clinic Comprehensive pediatric sleep clinic for complex sleep disordered breathing disorders. . . . . . . . . . . . 20 Pediatric Anesthesiology Finding new and better ways to manage cases and to make young ENT patients comfortable through surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 Otolaryngology Care Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Map, Location, and Contact Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

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Stanford Children’s Health

Stanford Children’s Health Otolaryngology/Head and Neck Surgery Program The benefits of specialization and coordinated whole-patient care The Stanford Children’s Health Division of Pediatric Otolaryngology/Head and Neck Surgery, also called the Ear, Nose and Throat (ENT) program, is one of the country’s premier programs.

It is home to a team of compassionate, skilled, and world-renowned physicians and surgeons who emphasize a patient-centered, multidisciplinary, and coordinated approach to conditions of the head and neck, while conducting innovative research to advance medicine on several essential fronts.

In addition to the acclaimed Aerodigestive and Airway Reconstruction Center and Children’s Hearing Center, the division’s several other clinics and centers encompass thyroid and endocrine disorders, cleft and craniofacial malformations, microtia and atresia, sleep disorders, vascular anomalies, and voice and swallowing disorders. The program’s overall excellence and the accomplishments of its specialized centers draw patients from all over California, throughout the nation, and around the world.

We understand that arriving at a diagnosis and treatment plan can be challenging and stressful for families. We value our patients’ time and have tailored our practice to help them navigate through this 4

Pediatric Otolaryngology

process. For example, doctors at the Children’s Hearing Center work closely with pediatric audiologists and speech-language pathologists to help the families of patients with hearing loss and other ear disorders to formulate a coherent diagnosis and plan, ranging from auditory rehabilitation using hearing aids to cochlear implantation. As proper hearing is critical for language development and learning in children, we work closely with the families and the children’s schools to optimize and personalize long-term treatment plans. Similarly, in the Aerodigestive and Airway Reconstruction Center, our team of otolaryngologists, pulmonologists, gastroenterologists, and speech-language pathologists provide care for families and patients, allowing these clinicians to form a cohesive diagnosis and treatment plan that is more convenient for the families and patients. The Airway Reconstruction team also works hand in hand with the Betty Irene Moore Children’s Heart Center to manage the most complex airway and lung abnormalities in children. At several other subspecialty clinics, including the Vascular Anomalies Clinic, the Voice and Swallowing Disorders Clinic, the Children’s Thyroid Center, and the Craniofacial Clinic, physicians from multiple specialties also work closely together to care for the families and patients, as we are mindful that some require care over months or even years. At Stanford Children’s Health, our team strives to generate a comprehensive and personalized treatment plan with the family.

If a procedure is needed, our programs not only help each young patient address his or her challenges, but also promote their well-being throughout treatment and beyond. For example, the PAWS program brings adoring and affectionate animals into the hospital to spend time with children pre- and postoperatively; the effect is calming and buoying for both children and families under stress. We also work with a team of pediatric anesthesiologists whose commitment and innovation are illustrated by their use of virtual reality to help allay anxiety and minimize anesthesia before and even during some procedures.

Finally, Lucile Packard Children’s Hospital Stanford’s affiliation with Stanford Health Care allows those young ENT patients who need ongoing care or periodic reviews to easily transition to adult care. Such continuity under Stanford’s extraordinary care not only comforts patients and their families as patients grow up, but also ensures that physicians’ understanding of each patient’s unique case continues to deepen as the patient matures.

Research also plays a key role in our efforts to help patients lead full and healthy lives. By constantly assessing the quality and outcomes of our current diagnostic and treatment paradigms, we are able to improve the care we deliver. Working alongside other innovative minds at Stanford and elsewhere in the Bay Area, the division’s physicians and scientists are currently investigating the efficacy of new surgical and medical therapies, such as the application of high-intensity focused ultrasound and cryotherapy to treat vascular malformations. To broaden the indications of cochlear implants in children, we were part of a multi-institutional study demonstrating safety results needed for FDA approval for implantation in children under 1 year of age.

Using 3-D printing of reconstructed CT scan images, our surgeons have optimized preoperative surgical planning to rebuild deficient microtia ears from autologous tissues. Moreover, we are studying novel imaging techniques to aid the diagnosis of various conditions ranging from voice and airway disorders to ear infections. In the laboratory, we are exploring novel signaling pathways to regenerate inner ear sensory cells with the long-term goal of restoring hearing loss in patients. These are just a few examples of how, through our research, we strive to improve patient care and shape the future of medicine. ent.stanfordchildrens.org

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Stanford Children’s Health

Stanford Advantage Research fuels clinical success Lucile Packard Children’s Hospital Stanford is proud to be the pediatric and obstetric teaching hospital of Stanford Medicine, which is one of the top-ranked academic medical institutions in the country, home to cutting-edge medical advances, including the first successful adult human heart transplant in the country and the first combined heart-lung transplant in the world.

Established in 1885, Stanford University is one of the world’s leading research universities and premier academic brands, particularly noted for top-ranked programs that include physical and biological sciences. Patients of all ages who receive care from the hospitals and community practices benefit from the Stanford University School of Medicine affiliation, which fosters multidisciplinary research, family-centered care, and groundbreaking innovation. Stanford Medicine encompasses the West Coast’s oldest medical school, a worldwide leader in patient care, education, research, and innovation.

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Pediatric Otolaryngology

New Hospital/New ORs One of the nation’s most technologically advanced, sustainable hospitals Lucile Packard Children’s Hospital Stanford is one of the most technologically advanced, beautiful, and environmentally sustainable pediatric medical facilities in the nation. A recent expansion added more than 500,000 square feet, allowing the hospital to amplify its impact on the lives of the children who come from around the world for treatment. The hospital includes new operating and interventional radiology rooms that promote new kinds of collaboration and that have faster and better imaging (including intraoperative MRI), which improve outcomes for more patients.

The new hospital also puts the calming, restorative influence of the natural world at the center of the patient experience. Parents, siblings, and patients all embrace the acres of new gardens and the many outdoor play spaces, fanciful nature-themed interactive sculptural environments, patios, and overlooks. Large windows allow each of the 149 new patient rooms to fill with natural light. All of the new rooms provide sleeping accommodations for two family members. Each floor has dedicated lounges, laundry rooms, and kitchens that help families take good care of themselves, decompress, prepare, and recuperate.

The new hospital’s extraordinary sustainability features include water recovery for landscape irrigation, creative use of recycled and reclaimed local materials, and an external shading system that reduces the need for air-conditioning.

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Aerodigestive and Airway Reconstruction Coordinated care for complex conditions The Aerodigestive and Airway Reconstruction Center at Lucile Packard Children’s Hospital Stanford is one of a select group of centers in the United States, and the largest center on the West Coast, dedicated specifically to the care of children with complex disorders of the airway, esophagus, and upper gastrointestinal tract.

At many hospitals, patients and their families must separately visit numerous specialists who each may offer complicated, and sometimes seemingly contradictory, analysis and advice. The pediatric Aerodigestive and Airway Reconstruction team streamlines the process by coordinating and integrating all parts of a patient’s care and collaborating with families. It prioritizes communication between the child, the family, the referring physician, and each of its own specialist members to ensure the smoothest, highest-quality, and most cost-effective care while considering the unique medical and social needs of each child and family.

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Families typically meet with multiple specialists in the same room, minimizing the number of visits, clarifying communication, and coordinating the patient’s care plan. After each visit, a full update is sent to the child’s primary care pediatrician, who is always kept in the loop.

The center’s specialists have a unique combination of training, experience, and expertise that allows them to address the complex needs of children with airway, swallowing, voice, lung, gastrointestinal, and other aerodigestive problems.

Specialists in pediatric otolaryngology/head and neck surgery (ENT), pediatric pulmonology,

Pediatric Otolaryngology

pediatric gastroenterology, nutrition, and speech and language pathology work in unison. In addition, they have established relationships with many other surgical and medical services, including but not limited to pediatric cardiothoracic and congenital heart surgery, pediatric cardiology, and cardiac anesthesiology. For example, it is the extraordinarily close partnership between the Aerodigestive and Airway Reconstruction team and the cardiothoracic surgery team that provides each thoracic slide tracheoplasty patient the highest-quality care and excellent outcomes. Similarly, the Aerodigestive and Airway Reconstruction Center has highly coordinated involvement in the specialized management of patients with DiGeorge syndrome as well as through their collaboration with the multidisciplinary Marfan Syndrome Clinic.

Respiratory therapists, nutrition specialists, social work specialists, occupational therapists, and parent mentors are also central to the program’s commitment to the well-being of the whole child.

Collaborations with other leading programs at Stanford Children’s Health—including the Center for Pediatric Voice and Swallowing Disorders; the Pediatric Vocal Cord Dysfunction Clinic; the Pediatric Heart Center; and Gastroenterology, Hepatology and Nutrition—complete the picture.

The center’s pediatric airway surgeons and aerodigestive team employ state-of-the-art imaging technologies—including CT scan dose minimization available at only two centers in the United States—and endoscopic techniques to evaluate the airways, esophagus, and upper gastrointestinal tract for individualized preoperative planning. In many cases, airway procedures and operations can be conducted using minimally invasive or endoscopic techniques, although open interventions are also performed when appropriate, with superb results. The surgical team reviews all surgical options and plans with the family. Through the collaborative leadership ent.stanfordchildrens.org

of airway experts Drs. Douglas Sidell, Kara Meister, Karthik Balakrishnan, and Tulio Valdez, the complex airway reconstruction component of the center is rapidly expanding to meet the urgent need for world-class, coordinated, patientand family-centered pediatric care in this field.

Stanford Children’s Health is home to leading researchers of international renown in the field of aerodigestive and airway reconstruction surgery.

These surgeon scientists have been leaders in the formation of aerodigestive and cardiac bronchoscopy registries and the development of international consensus on outcomes measurement following airway reconstruction surgery. They serve as elected representatives of the Aerodigestive Society and on the executive board of the national Aerodigestive Research Collaborative as founding members. In recent years, the center’s physicians have investigated feeding and swallowing dysfunction in children with airway disorders, the development of airway safety algorithms within the electronic medical record, the use of application-based ultrasound to identify vocal-fold motion disorders, and the efficacy of the Stanford CHARIOT program, which uses virtual and augmented reality to reduce anxiety in children during clinical procedures.

The Aerodigestive and Airway Reconstruction Center has also continued its mission to provide unparalleled treatment for children with congenital tracheal stenosis (complete tracheal rings). In collaboration with cardiothoracic surgery, cardiology, and cardiac anesthesiology, we have established the only center in California with a team dedicated to the repair and management of congenital tracheal stenosis. The center addresses a wide range of other conditions as well, including but not limited to laryngeal stenosis, laryngeal clefts, tracheoesophageal fistulas, fetal and newborn airway malformations, and complex laryngeal and tracheal trauma.

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Cleft and Craniofacial Center Experts in all types of craniofacial abnormalities The Stanford Children’s Health Cleft and Craniofacial Center provides world-class surgical reconstruction and medical care for children and adults. Because of the complexities of many of the conditions we treat, the coordinated work of multidisciplinary specialists is crucial to our success.

Pediatric otolaryngologists work closely with providers from more than a dozen subspecialties to develop the best possible treatment plan for the long-term care of cleft and craniofacial patients. The team cares for children with conditions that include cleft lip, cleft palate, craniofacial microsomia, microtia and ear canal atresia, velopharyngeal insufficiency (VPI), and malformations of the skull such as craniosynostosis. The center offers genetic testing and counseling, surgical reconstruction, speech therapy, hearing evaluations, and dental and orthodontic treatment, as well as psychological support.

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The center’s weekly Cleft and Craniofacial Clinic is attended by a team of leaders in their fields, each of whom has a passion for the care of children with cleft and craniofacial deformities. Specialists—including pediatric otolaryngologists, plastic/craniofacial surgeons, pediatric dentists, craniofacial orthodontists, geneticists, pediatric neurosurgeons, ophthalmologists, child psychologists, pediatric neurologists, oral and maxillofacial surgeons, speech pathologists, audiologists, and social workers—coordinate their efforts and combine insights to provide a comprehensive treatment plan tailored to each patient. Subgroups of the

Pediatric Otolaryngology

clinic meet for further subspecialty care, such as the Craniosynostosis Clinic, the Microtia and Atresia Clinic, and the VPI Clinic, to give even more focused care to these patients.

are present, engaging with the patients and their families and working together with the administrative staff. The group is dedicated to providing long-term continuity of care.

The clinic is a collaboration between all the providers so that individual care plans can be orchestrated considering the specific patient and family’s needs with the treatment goals of each subspecialty. The surgical plan is in alignment with the dental plan and orthodontic plan, all with an understanding and appreciation of the patient’s growth, development, hearing/ear health, swallowing, speech, breathing, and sleep quality. This allows for scheduled coordination of care, where each anesthetic event is an opportunity for specialties to work together to do what is best for the child. This is only possible through multidisciplinary clinic visits and postclinic conferences, where all providers

Research by our craniofacial physician scientists plays a crucial role in advancing medical knowledge as well as aiding the treatment of our patients. For example, we have recently conducted national database studies comparing the costs and outcomes of different approaches to craniosynostosis surgery. We have done a national database study on obstructive sleep apnea after VPI surgery in cleft palate patients. And we have collaborated with Anesthesiology to study ways to minimize opioid use after cleft palate repairs and revisions. We also are conducting research on reconstructive hearing surgeries and hearing aid options for children with ear canal atresia, and on the social implications of microtia.

The center’s weekly Cleft and Craniofacial Clinic is attended by a team of leaders in their fields, each of whom has a passion for the care of children with cleft and craniofacial deformities.

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Patient Story Coordinated care helps 4-year-old Jack thrive It was in the first moments after his birth that Jack Muñoz began the struggle for his life. His mother, Nakisa, immediately noticed that he was having difficulty breathing and was unable even to cry. Within just a few days, Jack had emergency surgery on his gastrointestinal tract, and he ultimately received a tracheostomy in his neck so he could breathe and remain safe.

Jack was only about a month old when he was transferred to Lucile Packard Children’s Hospital Stanford, where he was diagnosed with a genetic disorder known as DiGeorge syndrome. The syndrome can manifest in various ways, including combinations of problems with the airway, facial structure, gastrointestinal tract, and immune system. Jack suffered from complications in all of these areas and required several additional operations, including open-heart surgery. He was also diagnosed with a severe and complex malformation of the larynx and upper airway, and he would require a major operation before his tracheostomy could be removed.

Though they were relieved to have a clear diagnosis, Nakisa and her husband, Michael, were overwhelmed

by Jack’s multitude of doctor visits, by all the various streams of information and analysis coming in, and by the sheer amount of time Jack had to spend in the hospital. They were desperate to bring him home and to settle down into a family routine, but the constant checkups, consultations, and procedures made this nearly impossible. Shortly after his arrival at Packard Children’s five years ago, when Douglas Sidell, MD, connected with the Muñoz family and brought Jack into the hospital’s new Aerodigestive and Airway Reconstruction Center, things began to look up.

“A patient like Jack has a plethora of intertwined diagnoses and has probably taken many trips to the operating room for various reasons,” says Dr. Sidell. “While our center allows each of its multiple 12

Pediatric Otolaryngology

specialists to focus on their area of expertise, they are always aware of what the other practitioners are doing as well. We are all working together—in the clinic and the operating room—and we continually talk to each other. We take everything into account, including the family’s social situation, the child’s health status, and operations that may benefit the child in the future.”

In early 2015, still less than a year old, Jack underwent an extensive staged operation to reconstruct his trachea and his larynx, allowing him to speak for the first time and finally to breathe without a tracheostomy tube.

Although the surgery was successful and his tracheostomy tube was removed, the aerodigestive team knew that the job was not over. “The operative repair of the airway is not the end,” says Dr. Sidell. “In fact, it is often just the beginning. We keep our airway patients close. They have our personal phone numbers and can reach us by email day or night. Successful surgery not only means a good operation, it means adequate preparation up front, and years of follow-up and surveillance thereafter.”

Since the time of his surgery, Jack and his family have kept in close contact with the Aerodigestive Center and with Dr. Sidell. The team is here for him during routine clinic visits or unforeseen trips to the hospital, and they can talk to his family directly if things come up when they are away on vacation.

Since Jack’s operation, scores of patients with complex airway disorders have had airway reconstruction operations and received long-term care at the Aerodigestive and Airway Reconstruction Center.

Although many happy stories and successful outcomes have been accomplished during that time, Jack’s story marks the beginning of the multidisciplinary team approach for airway reconstruction in California.

“In 2014, this had been a long time coming,” says Dr. Sidell. “The decision to start this center was a no-brainer, and Stanford was the place to do it. Our center has served as the West Coast leader in this regard, and it is because of people like Jack and his family that we find the enthusiasm and energy to make this happen.”

The Lucile Packard Children’s Hospital Stanford Aerodigestive and Airway Reconstruction Center has grown to include more than 30 physician and specialist team members, providing care to hundreds of patients every year throughout the United States and Pacific Rim. Over the years, Nakisa has shared stories and pictures of Jack growing, traveling, swimming, and being a kid.

“This isn’t just more convenient and less stressful care for patients and their families,” says Dr. Sidell.

“It is better medicine, pure and simple.”

“ I treat all of my patients like I would want my own children to be treated, but I probably had a heightened sense of the Muñozes’ fears and frustrations.”

Douglas Sidell, MD

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Stanford Children’s Health

Microtia and Ear Canal Atresia Clinic Internationally recognized treatment, education, and research The Microtia and Ear Canal Atresia Clinic is dedicated to helping patients and their families understand these conditions and the very best options for their individual treatment.

An outgrowth of the Cleft and Craniofacial Center, the clinic provides a specialized focus on the reconstructive needs of children with this kind of ear malformation and the hearing loss associated with it. Kay Chang, MD, and Mai Thy Truong, MD, both active members of the International Society for Auricular Reconstruction (ISAR), co-lead the clinic and form its surgical core. Each patient also has access to a full interdisciplinary team, including otolaryngologists, audiologists, geneticists, and radiologists.

Every case is unique, and Drs. Truong and Chang help parents navigate through the numerous hearing and ear-reconstructive options to form the best individualized treatment plan for each child. Working closely with the audiology team at a child’s birth, the doctors review all hearing rehabilitative options, including surgery and hearing devices. If a family chooses to pursue microtia and atresia repair, Drs. Truong and Chang will help figure out not only what procedure or procedures might be best, but also the best age at which they should be undertaken.

The clinic’s surgeons employ 3-D modeling technology to improve surgical planning and to create a mirror image of the patient’s intact ear. Ear canal and middle ear reconstruction surgery are also available for patients with ear canal atresia. For those microtia patients with craniofacial microsomia causing jaw asymmetry and dental problems, the team may coordinate care with the Cleft and Craniofacial Center,

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where, if indicated, those patients can also receive genetic evaluation and consultation.

The research conducted by the clinic’s physicians improves care both for their own patients and for microtia and ear canal atresia patients everywhere.

Current studies include an examination of the social perception of patients with microtia and a statistical analysis of how ear canal atresia repair affects hearing in young patients.

As specialists in both the external ear and hearing, the clinic’s physicians and surgeons understand and take to heart the burdens that problems in either or both of these areas can put on families, and they provide coordinated support and care from the time a child with microtia is born, helping parents to navigate through what can be an intimidating array of stressful choices and treatment options. With a little assistance, the great majority of our patients are able to lead full and happy lives.

Pediatric Otolaryngology

Microtia Before and After Photos Before

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Surgical Plan: 3-D modeling

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Stanford Children’s Health

Children’s Thyroid Center Compassionate, coordinated care for children with thyroid conditions The Children’s Thyroid Center is one of only a few programs in the country that employ pediatric specialists from every aspect of thyroid care to address patients with thyroid nodules and thyroid cancers. The multidisciplinary team, which considers each patient from several points of view, includes pediatric endocrinology, pediatric otolaryngology/head and neck surgery, pediatric surgery, nuclear medicine, interventional radiology, genetics, radiology, oncology, and pediatric pathology. The breadth of this collaboration makes a huge difference, both for optimal case management and for the experience of patients and families.

A patient needing thyroid surgery, for example, will meet at the center before surgery, where the team of doctors will develop a coordinated treatment plan. Instead of getting multiple—and possibly divergent—perspectives, the patient and family get a single, unified explanation of the treatment plan, integrating its complementary surgical and medical components. Each plan is reviewed by the center’s surgical co-directors,

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Kara Meister, MD, and Gary Hartman, MD, and by medical director Hilary Seeley, MD. The Children’s Thyroid Center is also a home for children with a genetic predisposition to thyroid problems such as multiple endocrine neoplasia syndrome, DICER1 syndrome, PTEN hamartoma tumor syndrome, and others.

Pediatric oncologist Sara Kreimer, MD,

Pediatric Otolaryngology

coordinates surveillance, genetic evaluation, and additional treatment needed for these patients within the Children’s Thyroid Center.

diagnose and treat thyroid conditions, the rates of pediatric thyroid cancer, and childhood oncology and genetics related to thyroid problems.

Children in need of additional treatment for pediatric hyperthyroidism, or Graves’ disease, are evaluated for treatment with anti-thyroid medications, radioactive iodine treatment, or surgical management. Families are offered a full understanding of the risks and benefits associated with each type of treatment so they can choose the best treatment option for their child.

The new Lucile Packard Children’s Hospital Stanford’s operating rooms are equipped with advanced real-time ultrasound and nerve-monitoring equipment to improve intraoperative safety for our young thyroid surgery patients.

Cooperation and clear communication are central to the center’s success, and that commitment extends to every member of the team, including referring physicians, patients, and families. Especially in complicated cases, ensuring that everyone is well informed helps the whole team to stay on the best course forward, and it fosters a smooth and reassuring clinical experience for the patient and family.

Also central to the center’s mission is the research that helps the team improve its own clinical performance and advance the frontiers of thyroid treatment throughout the world. Thyroid Center clinicians’ research includes studies of the use of point-of-care ultrasonography to

Adult-focused thyroid surgeons and physicians at Stanford Health Care are also leading experts in the field, and the Children’s Thyroid Center’s affiliation with Stanford’s excellent Endocrine Tumor program ensures that patients enjoy continuity of world-class, expert care as they grow up. Should a patient be diagnosed with thyroid cancer later in his or her childhood, for example, and need to be treated by the Stanford Health Care team, those colleagues will consult with the Children’s Thyroid Center’s team at the time of diagnosis, during surgery and treatment, and again during the patient’s full transition to adult care. The center is committed to providing the best possible coordinated and complete care at every stage of patients’ lives.

Cooperation and clear communication are central to the center’s success, and that commitment extends to every member of the team, including referring physicians, patients, and families.

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Children’s Hearing Center: Audiology Helping children to hear and communicate Hearing loss is the most common congenital disorder, and it is associated with speech delays and difficulties in school. The Children’s Hearing Center, under the dual leadership of pediatric audiologist Melissa Tribble, AuD, and pediatric otolaryngologist Alan Cheng, MD, works closely with families, patients, and referring physicians to identify, diagnose, and treat children with hearing disorders. The center’s clinicians also focus on overcoming the barriers that hearing loss poses for the development of a child’s speech and other communication skills.

The center’s diagnostic services offer comprehensive, developmentally appropriate hearing evaluations for newborns, infants, and older pediatric patients. The center’s audiologists perform behavioral hearing evaluations in addition to auditory brainstem response evaluations, auditory steady state response evaluations, otoacoustic emissions testing, and middle-ear function assessments.

Evaluating hearing loss in young children can be especially challenging. Testing can sometimes be difficult, as it requires winning children’s cooperation during hearing tests, while hearing aids are being fitted or cochlear implants are being programmed. Stanford Children’s Health’s extraordinary pediatric audiologists work together with physicians and surgeons to put both patients and parents at ease. Making them comfortable is a first essential step toward getting the most complete and accurate diagnosis possible, and to discovering and conveying the best available options for treatment.

Cochlear implants give a growing number of children with severe-to-profound hearing loss access to sounds and spoken language. The Children’s Hearing Center’s multidisciplinary 18

pediatric cochlear implant team includes more than a dozen experts in the areas of speechlanguage pathology, audiology, and pediatric otology. The team has achieved excellent outcomes, even in nontraditional patients, including those with inner-ear malformations and single-sided deafness. The center has also had success using cochlear implants to help deaf children with Down syndrome and other developmental disabilities.

For young patients already diagnosed and living with hearing loss, the Children’s Hearing Center provides periodic hearing evaluations and hearing aid and assistive listening device consultations and services. The center’s audiologists and speechlanguage pathologist also counsel patients and parents regarding communication and educational options and aural rehabilitation. We strive to be partners with the community of educators and therapists who work with these patients on a daily or weekly basis. Through family-centered care, we work to provide the best audiologic and otologic services to meet the individual goals of each family. Our aim is to help children hear as well as they possibly can so that they can communicate confidently and effectively.

Pediatric Otolaryngology

Vascular Anomalies Accurate diagnosis and comprehensive interdisciplinary care The Vascular Anomalies Clinic helps children and adults with vascular malformations or vascular tumors, including hemangiomas, lymphatic malformations, venous malformations, and arteriovenous malformations. Our team of otolaryngologists, dermatologists, plastic surgeons, interventional radiologists, hematologists, oncologists, pathologists, and geneticists provides comprehensive, interdisciplinary care.

Assembling doctors from all relevant specialties in one place every other week is key to achieving excellent patient experience, diagnostic accuracy, and coordinated and innovative treatments. The team first goes over each patient’s radiological scans with specialist diagnostic radiologists. An active discussion ensues, each specialist representing a different perspective, and together the team thoroughly evaluates each case and zeroes in on an accurate diagnosis and optimal treatment plan.

Treatments vary depending on the type of malformation, the region of the body affected, and each patient’s needs and medical history. Our group specializes in surgery, minimally invasive procedures, and medical therapies. Some novel approaches use minimally invasive interventional radiology (IR) techniques such as freezing, sclerosing, heating, embolizing, and otherwise destroying errant blood or lymph vessels. Others rely on a deepening grasp of the genetics underlying vascular anomalies; targeted medical treatment of vascular abnormalities based on genetic understanding is increasingly effective, either as primary therapy or as an adjunct to

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IR and/or surgery. Some medications from the oncology armamentarium can be repurposed to shrink vascular anomalies. Operations to resect or debulk vascular anomalies are performed by surgeons with vast experience in this field. Other interventions include cutaneous dermatologic surgery using laser technology to improve cosmesis and reduce complications such as pain and bleeding. In most cases, specialists from different fields work together, either in stages (shrinking the lesion with medications and then treating it surgically, for example) or in single, multistep, multimodal procedures.

The team’s clinician scientists are examining genetic associations for different vascular anomalies, an approach that has led to the effective repurposing of chemotherapy drugs. Others are studying surgical-medical combination therapies as well as the use of high-intensity focused ultrasound and cryotherapy for treating challenging vascular tumors.

Whichever treatment options are recommended in the clinic, they will be precisely targeted for the patient’s best odds for success.

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Complex Sleep Disorders Clinic Comprehensive pediatric sleep clinic for complex sleep disordered breathing disorders Good sleep is key to a child’s health. Optimal growth, normal immunological function, normal brain development, and cardiovascular well-being all depend on it. Otolaryngology, in collaboration with the Pediatric Pulmonology, Asthma and Sleep Medicine Center, is establishing a multidisciplinary Complex Sleep Disorders Clinic. This clinic will evaluate patients with various medical issues affecting sleep to develop a comprehensive, multidisciplinary treatment plan.

The clinic will specialize in the medical and surgical evaluation of sleep disordered breathing in patients with complex medical conditions that include but are not limited to neuromuscular disease, genetic syndromes, craniofacial abnormalities, and morbid obesity. Collaborative relationships have also been established with other relevant specialties, including psychiatry for insomnia and mental health issues, craniofacial and maxillofacial surgery, and pain management and integrative medicine.

The clinic’s state-of-the-art diagnosis of children with sleep disordered breathing will employ sleep endoscopy, a technique that can identify areas of obstruction, which is important in children whose disordered sleep is not caused by their tonsils or adenoids. Their apnea often can be effectively addressed with tongue-base and/or epiglottis

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surgery. Mild palate abnormalities sometimes result in narrow airway passages that also can affect breathing during sleep; this condition can now often be successfully managed with dental appliances, again bypassing unnecessary surgery. Patients who are not candidates for surgical intervention will be managed by pediatric pulmonary and sleep medicine physicians who prescribe advanced noninvasive ventilation therapy with close follow-up in the pediatric sleep clinic.

The clinic’s primary goal is to provide comprehensive and multidisciplinary care for patients with complex sleep disordered breathing disorders in an efficient and effective manner, minimizing the need to make multiple appointments and reducing the time taken for diagnosis and treatment.

Pediatric Otolaryngology

Pediatric Anesthesiology Finding new and better ways to manage cases and to make young ENT patients comfortable through surgery Children with congenital anomalies of their airways often require delicate and recurrent interventions and surgeries calling on several subspecialties, and the anesthesia team must be able to work closely with each of these, focused on its particular task but always keeping the big picture in mind. While clinical acumen and clear communication are two keys to successful anesthesia in any surgical field, because managing the airway is a fundamental aspect of pediatric anesthesia management, these foci are especially important when surgery is conducted around the head and neck.

Otolaryngologists and anesthesiologists have a particularly close relationship, even in a program as coordinated and multidisciplinary as Stanford Children’s Health’s ENT. They work side by side in critical situations, and both manage relatively healthy patients for routine disorders of the tonsils and adenoids and for the insertion and management of ear tubes. Together, they manage critical airways in operating rooms, intensive care units, and emergency departments.

Many ENT patients have complex congenital heart disease, abnormal airways, or other coexisting illnesses, so their anesthesiologists must be adept at predicting and monitoring the pharmacodynamics and pharmacokinetics of drugs in the most complex ENT patients, from the smallest newborns to young adults.

Undergoing ENT surgery can be especially stressful for children. Stanford’s uniquely innovative academic environment brings together

ent.stanfordchildrens.org

physicians, engineers, researchers, and child life professionals dedicated to relieving some of that stress. In 2017, the pediatric anesthesia group launched the CHARIOT program, which uses virtual reality (VR) to help allay perioperative anxiety for young patients and in some cases even reduce the need for pain medication. The team is currently quantifying the effectiveness of VR and is also experimenting with other simulation technologies to advance the frontiers of safe and reproducible education programs.

Stanford Children’s Health’s anesthesiology research drives continual improvement in the clinical practice, while insights from the clinic inform and deepen the research, which includes studies of the management of congenital heart diseases, pediatric pain (both acute and chronic), regional anesthesia techniques for children, patient safety, and process improvement.

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Stanford Children’s Health

Otolaryngology Care Team

Alan G. Cheng, MD Chief, Division of Pediatric Otolaryngology Areas of Expertise Cochlear Implants, Hearing Loss

Iram Ahmad, MD, MME Areas of Expertise Cochlear Implants, Hearing Loss

Christi Arnerich, MD Area of Expertise General Pediatric Otolaryngology

Karthik Balakrishnan, MD, MPH, FAAP, FACS Areas of Expertise Aerodigestive Disorders, Airway Reconstruction, Vascular Anomalies, Velopharyngeal Insufficiency

Kay W. Chang, MD

Peter J. Koltai, MD

Kara Meister, MD

Douglas Sidell, MD

Areas of Expertise Cochlear Implants, Hearing Loss, Microtia, Ear Canal Atresia

Area of Expertise Complex Obstructive Sleep Apnea

Areas of Expertise Aerodigestive Disorders, Airway Reconstruction, Thyroid Disorders

Areas of Expertise Aerodigestive Disorders, Complex Airway Reconstruction Voice and Swallow Program

Mai Thy Truong, MD

Tulio A. Valdez, MD, MSc

Areas of Expertise Cleft and Craniofacial, Microtia, Vascular Anomalies

Areas of Expertise Aerodigestive Disorders, Complex Obstructive Sleep Apnea, Voice and Swallow Program

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Pediatric Otolaryngology

Map, Location, and Contact Information

Solano

Marin Ear Institute 2452 Watson Ct., Suite 1500 Palo Alto, CA 94303 Tel (650) 724-4800 Fax (650) 498-2734 Mary L. Johnson Specialty Services 730 Welch Rd., 1st Floor Palo Alto, CA 94304 Tel (650) 724-4800 Fax (650) 498-2734 Specialty Services – Emeryville 6121 Hollis St., Suite 2 Emeryville, CA 94608 Tel (510) 587-9600 Fax (510) 587-9606

Emeryville

Walnut Creek Contra Costa

San Francisco

Alameda Fremont

San Mateo Palo Alto

Lucile Packard Children’s Hospital Stanford Los Gatos

Specialty Services – Fremont 2299 Mowry Ave., Suite 2A Fremont, CA 94538 Tel (925) 239-2900 Fax (925) 932-2456 Specialty Services – Los Gatos

Santa Clara Santa Cruz

14601 S. Bascom Ave., Suite 200 Los Gatos, CA 95032 Tel (650) 724-4800 Fax (650) 498-2734 Specialty Services – Walnut Creek* 106 La Casa Via, Suite 100 Walnut Creek, CA 94598 Tel (925) 239-2900 * In partnership with John Muir Health.

Fax (510) 587-9606 ent.stanfordchildrens.org

Christi Arnerich, MD sees patients in three East Bay locations and performs surgery at John Muir Health Walnut Creek.

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Contact Us For more information, visit ent.stanfordchildrens.org or call (650) 724-4800

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