Looking Deeper: Manifestations of COVID Related Stress in the Pediatric ENT Office

October 8, 2021

Many of us are seeing the ongoing mental health impact of the COVID pandemic, as young kids and adolescents are struggling now more than ever with depression, anxiety and stress, often to overwhelming degrees, ending up in the emergency department and looking for hard-to-find inpatient mental health beds. But what about the kids who are processing their stress, anxiety and trauma primarily through physical symptoms? How might kids be presenting to our offices with physical complaints that are exacerbated by stress and how might we help them?

Here to talk to us about a few ways that psychosocial symptoms show up in the pediatric ENT office is Dr. Tim Lander, medical director of our Pediatric ENT program here at Children’s Minnesota.

Tim Lander, MD


Dr. Angela Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, where the complex is our every day. Each week, we bring you intriguing stories and relevant pediatric healthcare information as we partner with you in the care of your patients. Our guests, data, ideas and practical tips will surprise, challenge and perhaps change how you care for the most amazing people on earth, kids. Welcome to Talking Pediatrics. I’m your host, Dr. Angela Kade Goepferd.

It has been quite the year for us in healthcare, as well as for the kids in our care. Many of us are seeing the ongoing mental health impact of the COVID pandemic as young kids and adolescents are struggling now more than ever with depression, anxiety, and stress, often to overwhelming degrees ending up in our emergency departments and looking for those hard to find inpatient mental health beds. But what about the kids who are processing their stress, anxiety and trauma, primarily through physical symptoms. How might kids be presenting to our offices with physical complaints that are exacerbated by stress and how might we help them? Here to talk to us today about a few ways that psychosocial symptoms show up in the pediatric ENT office is Dr. Tim Lander, medical director of Children’s ENT and Facial Plastic Surgery Program here at Children’s Minnesota. Dr. Lander, thanks for joining me today.

Dr. Tim Lander: Well, thank you, Angela. It’s really a pleasure to be here and thank you for inviting me.

Dr. Angela Kade Goepferd: Well, you and I know each other quite a bit, but I don’t actually know the answer to this next question. You are a pediatric otolaryngologist, which is a mouthful. How did you decide that that was the field for you? What drove you into pediatric ENT?

Dr. Tim Lander: ENT is a surgical specialty. And so our training is slightly different than many of the other pediatric specialists that work at Children’s. Coming through a surgical education, we actually choose our surgical specialty before deciding to go into pediatrics, which is different than, say a pediatric cardiologist or a general pediatrician. They generally decided to become a pediatrician and then go on to subspecialize in different areas of pediatric medicine. So when I decided to go into ENT, I had no idea that I would end up as a pediatric ENT. It involves an additional year of training after completing a residency in otolaryngology. And I decided I wanted to move back to the Twin Cities from where I was doing my general ENT training. And one of the best jobs in town at that time was working with a man named Jim Sidman.

And the only caveat to working with Jim Sidman was that I had to decide to specialize in pediatrics. And so that’s how I ended up as a pediatric ENT doctor. And it’s been a really good fit for me. When I was growing up and even into my young adulthood, didn’t really have a lot of experiences interacting with children and actually I would have described myself as not very good with kids. So choosing pediatrics was not a very natural fit for me, but as I’ve practiced in this area of specialization, I’ve grown to really love it. I love interacting with the kids. It feels very natural to me now, and I really enjoy the work that I do.

Dr. Angela Kade Goepferd: Often as pediatric clinicians, when we think of ENT, I think the big things that come to mind are ear tubes, adenoids, tonsils. I’m sure you do so much more than that. What are some of the other common reasons that kids would get referred to a pediatric ENT?

Dr. Tim Lander: Most of us that go into pediatric ENT are attracted to the wide variety of surgical procedures that we do. One of the things that’s very common in medicine now is increasing subspecialization. So when you complete an ENT residency training program, you may choose to subspecialize in just ear surgery or just laryngology, which is treatment of disorders of the voice, for example. One of the things that attracts many people to pediatric ENT as a specialty is that you still get to practice the entire breadth of what you learn as an otolaryngologist. You just treat children and adolescents. So we do complex ear surgery, we reconstruct ear drums, we can rebuild the little bones inside the ear that help us hear.

We do cochlear implantation for children who are either born deaf or acquire deafness through disease or illness. A large part of our specialty involves treatment of airway disorders. So children who have structural problems with their breathing, they’re born with an abnormally small windpipe or area of the voice box, or that part of their anatomy is damaged during early childhood. That’s a large part of what we do is diagnose and treat airway disorders. And then of course we do all of the more complicated procedures and take care of the more complicated problems that you’ll see in a regular ENT clinic office, such as complex sinusitis, patients with cystic fibrosis and those types of things.

And what makes our practice a little bit unique in the spectrum of pediatric ENT care is that we also have a number of our partners that have special training in pediatric facial plastic surgery. So we have a large cleft and craniofacial program. One of my favorite types of patients to see, and one of the favorite types of surgeries I do is reconstructing soft tissue defects in the face. So children who are born with congenital nevus or lesions on their face, or who have had severe facial trauma from say, dog bite injuries or accidents, rebuilding the soft tissue of the face and modifying facial scars and things like that. So it’s a really wide variety of things that we take care of, not just ear tubes and tonsils.

Dr. Angela Kade Goepferd: Is there anything that you think people would be surprised to know that pediatric ENT does where a clinician might think, “Oh, I didn’t know I could send someone to ENT for that.”

Dr. Tim Lander: There’s a number of things. One of the most common things that people aren’t aware that we take care of are birthmarks. So children who are born with so called port-wine stains, capillary malformations, or hemangiomas of infancy. We’re oftentimes participating with our hematology, oncology and dermatology colleagues to take care of those. Another very common thing that we take care of that people are surprised to know is what I was talking about earlier, facial scars, soft tissue trauma. And then a big part of our practice is actually what you describe as head and neck surgery. So these are congenital or acquired neck masses, not often malignant, but sometimes so, and congenital masses within the neck and in the head are actually quite common in pediatric experience. And so we’re not just your nose and throat. We’re actually head and neck surgeons as well.

Dr. Angela Kade Goepferd: So I mentioned in the opening that the last year and a half have been particularly stressful for kids. They’re in the middle of enormous change and uncertainty during the COVID pandemic. And prior to today, we were talking about that there are a few ENT diagnoses that you’ve been seeing with greater frequency because of their association with psychosocial symptoms. Can you let us in on what those might be and what you’re seeing more of?

Dr. Tim Lander: I don’t think it will come as a surprise to anybody who’s listening, who takes care of children and adolescents, and I’m speaking primarily of parents as well. Being a child and a teenager nowadays is incredibly stressful, even before the pandemic and with these significant changes in lifestyle brought on by the pandemic. Losing social interaction with friends, kind of changing how we interact with the world and almost being confined to a virtual interaction with the world and all of the unusual things that kids are exposed to through a virtual environment, I think has just heightened the stress and anxiety amongst all children and adolescents. As a medical director of a pediatric ENT program, I do participate in nationwide conversation with my co-medical directors across the country. And it’s been very interesting to hear the conversations. And not just here in Minnesota that we’re seeing an increase in these anxiety-related ENT presentations, but it’s something that all of my colleagues across the country are seeing. When I started thinking about what conditions that we’re seeing an increased presentation for that may be related to anxiety, one of them is something called tinnitus.

This is a relatively rare problem in the pediatric space. Much more common in older individuals, oftentimes suffering hearing loss. But we’re starting to see a lot more adolescents coming in with complaints of tinnitus. What is tinnitus? Well, a lot of people know this as tinnitus, but as someone once told me, tinnitus just means infection of the tin or inflammation of a tin. So the conditions actually pronounced tinnitus. And this is that ringing in the ears that almost everybody on the planet has experienced, one time or another. But when patients present with tinnitus, it’s more of a constant sensation of a ringing or a noise in the ear. The definition is really any type of noise that someone perceives to be coming from their ear or ears that they know doesn’t really exist or that other people can’t actually hear.

What’s unknown about tinnitus is that it has a number of different causes, but the vast majority of tinnitus is actually thought to be a central nervous system phenomenon. There’s a part of the brain stem that process audiologic signaling. And there’s a part of it called the dorsal cochlear nucleus. And most of the recent research suggests that the vast majority of tinnitus actually arises in this location of the brain stem. So it’s actually not even noise that exists or is produced within the ear or the cochlear itself. Why are we seeing more of it now? Well, it turns out that tinnitus is oftentimes a manifestation of increased anxiety or stress. And makes it very difficult for primarily adolescences to concentrate.

Dr. Angela Kade Goepferd: Sure.

Dr. Tim Lander: Particularly if they are placing demands on themselves, such as listening through headphones to an entire day of virtual schooling, not having the appropriate breaks during the day to get out, socialize, exercise and those sorts of activities. And so we all suspect that that’s playing a role in the increased presentation of the condition.

Dr. Angela Kade Goepferd: So if I have a teenager who comes into my office and is complaining of tinnitus are there things that I can recommend, or when is it appropriate for me to refer to you and your colleagues to intervene?

Dr. Tim Lander: The type of tinnitus that we would be concerned, that would require an active medical or surgical treatment would be tinnitus that is pulsitile.

Dr. Angela Kade Goepferd: Okay.

Dr. Tim Lander: That’s unilateral. In other words, just one ear only, or is associated with other types of hearing symptoms. So fluctuating hearing, dizziness, pain or pressure in the ear, those would all be signs that there may be something more significant going on. Fortunately, those symptoms are quite unusual or quite rare in my experience. And usually the only symptom is the tinnitus itself. In those situations, we usually recommend getting a hearing test, because sometimes tinnitus can be a sign of hearing impairment, but almost never in the adolescent population. And then the mainstay of treatment is actually something called cognitive behavioral therapy, which really focuses primarily on stress reduction techniques, as well as coaching your brain to simply ignore the noise. And that’s usually where the treatment is focused towards.

Dr. Angela Kade Goepferd: And are there particular folks who would administer that treatment or any psychology professional?

Dr. Tim Lander: Interestingly, cognitive behavioral therapy to my understanding is primarily used in substance abuse and addiction medicine. So usually when we’re looking for resources to help patients with severe cases of tinnitus, we usually contact members of the healthcare professional that have experience in those areas of practice because they usually are familiar with cognitive behavioral therapy. Fortunately, most of the time, parents and adolescents are just reassured that there’s nothing severe going on, that this is a manifestation of increased stress and anxiety. And most patients are actually pretty good at developing stress-relieving activities on their own on with a little bit of guidance and a little bit of help. So that’s where I would focus your recommendations primarily.

Dr. Angela Kade Goepferd: The second condition that you had mentioned was something called globus sensation. Can you describe that for us and what that is?

Dr. Tim Lander: I think this may be one of the more surprising connections between anxiety, stress and visits to the ENT office. So globus sensation, fancy term for a sensation of something stuck in the throat or difficulty swallowing. The most common presenting symptom or complaint we have is, it’s usually an older child or an adolescent who experiences the sensation that there’s something stuck in their throat or it’s difficult to swallow. And yet when you ask the patients further, they typically don’t actually have any trouble swallowing. In other words, they’re not losing weight, they generally haven’t changed or modified their diet significantly. It’s just a sensation that it’s hard to initiate or to complete the swallowing mechanism. Globus sensation is really a manifestation of something called cricopharyngeal muscle spasm. And so the way that I typically explain this to patients and families is that, think about how we’re put together from mouth to stomach.

So when we are eating or drinking, we like to divide the process of consuming food or beverages into two phases. The first phase is a voluntary phase. The second phase is involuntary. So during the voluntary phase, you place something in your mouth, you can decide how long to keep it in your mouth, you can chew it as long as you need to, and then at some point you consciously decide that it’s time to swallow that food bolus. We bring the food to the back part of our mouth, we elevate our tongue and initiate a swallow. Once you initiate that swallow, your involuntary nervous system takes over and you really can’t stop a swallow at that point. If you’ve ever had one of your friends try to make you laugh while you’re drinking milk, is sort of the classic example, and you start choking and gagging in the middle of that involuntary swallow, the fluid goes in the wrong place.

So it ends up going down your windpipe rather than down your esophagus and into your stomach. So that’s why we’re put together that way. And that mechanism is designed to keep our airway safe. And what happens right after the initiation of that swallow is, there’s two areas of your esophagus that prevent food from coming back up. So the first one is called the upper esophageal sphincter. It’s essentially a ring of muscle at the top of the esophagus and that muscle relaxes to allow the food bolus to then enter the upper part of the esophagus. Once the food bolus is passed the upper esophageal sphincter, that sphincter closes back down to prevent the food from coming back up into the back of your mouth. Then there’s actually muscles within the esophagus to propel the food bolus into the lower part of the esophagus. This usually takes between five and 10 seconds.

And then the lower esophageal sphincter, which is at the bottom of your esophagus, opens up and the food bolus empties into your stomach. And then that lower esophageal sphincter closes again to prevent the food from coming back up into your lower esophagus. That’s how it’s supposed to work. What happens in some patients, and this is where the stress and anxiety piece comes into it, we do know that stress and anxiety can relate to an increased risk of what’s called gastroesophageal reflux. I think this is something most people now are quite familiar with. We call it GERD for short, but that’s basically a fancy term for heartburn. And essentially what happens in gastroesophageal reflux disease is that lower esophageal sphincter loses some of its normal resting muscle tone, gets a little loosey goosey and allows stomach contents or acid to actually reflux back up into the lower part of the esophagus. Well, believe it or not, the body actually has pH sensors. Special nerve endings that can detect the presence of stomach acid in the lower part of the esophagus where it doesn’t belong.

And one of the neurologic mechanisms that then kicks in is your brain sends signals to that upper esophageal sphincter muscle to tighten up even more to prevent that stomach contents from coming back up into the back of your throat. If you have ever had the unfortunate situation where you’ve been sick and been throwing up, that nauseated feeling you get, you’ll notice that right before you throw up, you can actually feel your throat tightening, you can actually feel an increase in saliva production. These are all mechanisms by which your body is preparing for vomiting. And to prepare you from preventing that vomit from getting sucked back down into your airway.

And so these are the symptoms that occur on a much smaller scale in patients who suffer from globus. So that tightening of that upper esophageal sphincter muscle creates the sensation of a foreign body sensation, difficult to swallow. It’s hard to get the food or fluid to get past that first step in the swallowing mechanism because that muscle is abnormally tight. The other symptoms that we frequently hear patients complain of when they have globus is, it’s a sensation that they have difficulty breathing. And what’s really interesting about that is they really don’t have any trouble breathing.

Dr. Angela Kade Goepferd: Right.

Dr. Tim Lander: In other words, they can still exercise normally, and they don’t have any abnormal airway noise, but they get that sensation that it’s hard to breathe. And that’s because that upper esophageal sphincter muscle is right on the back of your voice box. So when it tightens, it sends abnormal signals to your brain telling you that there’s something pressing on your voice box. And that is interpreted as a sensation of air hunger, even though there isn’t any physical airway obstruction. And then the final symptom that the patients will complain of is this kind of throat clearing. They seem like they’ve got a lot of phlegm, they’re constantly having to clear their throat and that’s caused by that increased salivary flow.

You actually produce more secretions in anticipation of having to dilute that acid that may be coming out. What’s really interesting is that in the pediatric population, it’s very rare for these patients to complain of the typical heartburn symptoms. So they usually don’t have a burning sensation in their chest. They don’t typically have the experience of acid reflux disease. They’re not burping or those types of things that we oftentimes associate with it. So it’s what we call silent reflux disease. And it’s treated very simply with antiacid medication. And in the pediatric population, usually a three to four week course of a mild antiacid is all you need to do to take care of the problem.

Dr. Angela Kade Goepferd: For kids who are experiencing this, who feel like they have something stuck in their throat, they are clearing their throat constantly, sometimes they might say it’s hard to breathe, how would you diagnose the globus sensation versus something else that might be going on that would be causing this? And again, when might I make that call in my office, or when might I ask you for help?

Dr. Tim Lander: Yeah, it really comes down to that careful history. It’s extremely difficult to diagnose these conditions objectively. In other words, using any types of tests. There really isn’t a good blood test or a radiology test for these conditions that you can order or that you can really differentiate. It’s a very thoughtful, careful history taking and being familiar with the classics signs or symptoms. What I typically do in my own practice when I’m fairly convinced that that’s what’s going on is I treat the children, what we call, empirically.

Dr. Angela Kade Goepferd: Mm-hmm (affirmative).

Dr. Tim Lander: So I give them a 30-day course of antiacid medication. The vast majority of them will achieve symptom relief within one to two weeks. And typically, it will go away. And interestingly enough, it generally doesn’t recur once you’ve adequately treated it. If for some reason after a month or two of adequate treatment the symptoms haven’t improved at all, or they are getting worse, then I typically refer to one of my gastroenterology colleagues for further evaluation, because there are some unusual conditions of the esophagus that can sometimes present with similar symptoms and oftentimes those actually do require an exam and a biopsy.

Dr. Angela Kade Goepferd: And then the last thing that you mentioned you’ve been seeing more of is vocal cord dysfunction, which I think all of us in pediatrics have probably seen at least once in our career. It’s not that uncommon, but you are seeing more of it and presumably similarly triggered by stress and anxiety.

Dr. Tim Lander: Yeah. This is a condition that’s very well known within the ENT world for being related to underlying stress or anxiety. Vocal cord dysfunction, it’s a funny name for this condition. Essentially what happens in vocal cord dysfunction, also sometimes called paradoxical vocal fold movement, vocal cord dysfunction is an abnormal movement of your vocal cords with the normal respiratory cycle. So when we breathe in, our vocal cords actually open to allow air to get into our trachea. When we exhale, the vocal cords gently close down a little bit. And of course when we swallow, the vocal cords close completely to prevent food or fluid from getting into our windpipe. When a child suffering from paradoxical vocal fold movement, the vocal cords are actually moving in the wrong direction with respect to the respiratory cycle. So instead of opening during inspiration, when we’re taking a breath in, they actually close when we’re taking a breath in. And you can simulate this yourself. If you voluntarily close your vocal chords when you try to take a breath in what happens? This happens.

And so the classic symptoms of vocal cord dysfunction are usually adolescents who present with that noise called stridor. And it’s generally a high pitched inspiratory noise. And it’s usually exacerbated by competitive physical activity. The classic scenario is the highly competitive athlete who puts a lot of abnormal stress or pressure on themselves to perform. And it’s a physical manifestation of an underlying mental conflict or desire to overachieve. Some people think that this is something in, what we call in medicine, a conversion reaction, which is essentially a physical manifestation of internal mental conflict. What’s really important for both the parent and the child to understand is, this is not intrinsically what you would describe as a mental illness, and it is a true physical manifestation.

In other words, it’s not the situation where, “Oh, it’s all in your head. This is something wrong with you, psychologically.” It is truly something that the patients cannot control. And it’s something that is, like I said, it’s a manifestation of underlying anxiety. If you treat the underlying anxiety, the problem typically goes away. The other thing that’s very interesting about this condition is that oftentimes it lives on a spectrum between anxiety and full blown panic disorder. And when patients suffer these episodes of air hunger during physical activity, and it can sometimes be bad enough that the kids can actually pass out, that almost leads to increase in panic.

Dr. Angela Kade Goepferd: Sure.

Dr. Tim Lander: They can feel these episodes coming on. They feel like they’re losing control. They feel like they’re going to have one of these episodes and they don’t know what to do and it breeds a full on panic disorder. And so recognizing that that’s what’s happening is obviously the first step in fixing the problem. It’s another one of these conditions that once you recognize it and you explain to the child and the family that there is a name for it, that we know what’s happening, that this is a very well described phenomenon and it’s actually anxiety or stress-related, that’s half the battle.

Dr. Angela Kade Goepferd: Yeah.

Dr. Tim Lander: Oftentimes the problem would be very easy to control thereafter. And the patients are unbelievably comforted by the fact that there isn’t really anything physically wrong with them.

Dr. Angela Kade Goepferd: Yeah.

Dr. Tim Lander: That there isn’t anything wrong with their performance and that they can compete without risking their life, for example.

Dr. Angela Kade Goepferd: Sure.

Dr. Tim Lander: Yeah.

Dr. Angela Kade Goepferd: Sure. And is there any specific therapy that… Physical therapy or other things that kids can do to help?

Dr. Tim Lander: Not surprisingly the treatments are the same as the other two-

Dr. Angela Kade Goepferd: Sure.

Dr. Tim Lander: … things that we’ve already talked about. It’s usually attention to the underlying anxiety disorder and stress reduction techniques.

Dr. Angela Kade Goepferd: Well, thank you so much for coming to talk to us today. I think so many of us who are taking care of kids right now are so worried about their mental health and what they’re going through. And often in kids, their bodies will process stress in physical symptoms, and so it’s really helpful to hear about these common ENT conditions that might be flaring right now due to stress and anxiety. And now we all know how to say tinnitus correctly, which is a bonus. Well, thanks for all that you do for kids and thanks for joining me.

Dr. Tim Lander: Thank you, Angela. It’s been a pleasure.

Dr. Angela Kade Goepferd: Thank you for joining us for Talking Pediatrics. Come back each week for a new episode with our caregivers and experts in pediatric health. Our executive producer and showrunner is Ilza Vogel. Episodes are engineered, produced and edited by Jake Beaver. Lexi Dingman is our marketing representative.

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