Non-Surgical Treatment for Pierre Robin Sequence with Dr. HyeRan Choo

In this episode of Scrubcast, host Rachel Baker interviews Dr. HyeRan Choo, a clinical associate professor in the Division of Plastic and Reconstructive Surgery at Stanford University. Dr. Choo discusses her journey into dentistry and orthodontics, which began in Korea.

Dr. Choo is doing innovative work treating Pierre Robin Sequence—a rare congenital condition—using a non-surgical method. This novel approach, developed to alleviate the condition's characteristic symptoms without surgery, scoops the tongue out of the airway, allowing immediate relief for affected babies. So far, Dr. Choo has treated 25 babies with the Orthodontic Airway Plate.

The episode concludes with Dr. Choo sharing valuable advice and acknowledging her mentor, Dr. Park.

Rachel Baker: [00:00:00] Welcome to Scrubcast, where we take a closer look at the research happening at Stanford University's Department of Surgery. I'm your host, Rachel Baker. Today, we're speaking with Dr. Heran Chu. Welcome to the show.

Dr. HyeRan Choo: Hi, Rachel. Thank you for having me.

Rachel Baker: Dr. Chu is a clinical associate professor in our Division of Plastic and Reconstructive Surgery and ADDS.

Why did you choose teeth?

Dr. HyeRan Choo: Um, I had no clue. I was born and grew up in Korea and when you go to college, you kind of hear what teacher tell you. Like, I think you're good at this. So whatever, uh, you get that entrance exam score and then you kind of go to where you, like teachers or your relatives, uncles tell you that it might be a good fit.

So that's how I ended up going to dentistry first. I had no clue, really. Thankfully, when I got in there, it was a good fit. It had a lot of [00:01:00] opportunity to use my hands. And come up with some, you know, some making things. Oh, I think I like making things with hands. So it was good.

Rachel Baker: Nice. Well, so it seems like early on in your career I was stalking your cv and looks like you you knew you didn't want to go into like private practice You received a combined degree in natural sciences and dental surgery from seoul national university before doing orthodontic residency and a master's at UAB.

And yet, I think actually what you're most well known for, at least at Stanford, is a non surgical approach. Something you innovated for, Pierre Robin's Sequence, which is a rare congenital disease I've never heard of before. Can you tell us what it is?

Dr. HyeRan Choo: Yeah, it's a very complex condition. So it's a clinical diagnosis, not based on the genetic testing.

So when you have these three very characteristic traits, which is very small chin, we call it [00:02:00] retrognathia, and then glossoptosis is a prolapsing tongue blocking the upper airway. And also going to have a, uh, upper airway obstruction validated by the sleep test. When you have those three, we can diagnose this baby who has a, uh, Roubin sequence.

And even though it's not diagnostic criteria, more than 80 percent of the Roubin babies actually have a cleft palate as well.

Rachel Baker: Oh, interesting. And so then this makes it hard to eat,

Dr. HyeRan Choo: breathe? So because of these very challenging anatomies, it's very hard. Babies will experience failure to thrive, meaning like hard to breathe and hard to eat, which are, you know, essentially the most important thing in their lives during this stage.

Rachel Baker: So classic treatment for this appears to be surgical in terms of repairing the cleft palate and, uh, distraction, osteogenesis, which sounds like a lot. It's [00:03:00] hella painful, by the way.

Dr. HyeRan Choo: So the reason that babies have breathing difficulty is because the tongue blocking the airway. So the goal is to bring the tongue forward, but since there is no way we can bring the tongue forward, surgically, we kind of elongate the jaw bone, which has the muscular attachment to the tongue.

So when the jaw bone comes forward, hopefully the tongue will come forward. So behind the tongue, that there is more breathing room. That's the concept. Got it. The hardware is you install on both sides of the jaw and then you cut the bone in between those, you know, in the middle. So lower jaw becomes three pieces.

So you start elongating those separated pieces. You separate and then in the middle on the separated, the gap will have a regenerated bone. So that's how we elongate the jaw. jawbone.

Rachel Baker: Wow, that sounds really intense. What made you think there might be a better [00:04:00] way? So initially I didn't see

Dr. HyeRan Choo: this neonate. I dealt with the kids who comes to my outpatient clinic and with the complaints of, oh, I can't open my mouth.

Well, my teeth are not growing, you know, I still have a sleep apnea and I'm thinking to have another, when I say I, it means the parents. We need to do another jaw surgery to open up the airway and then they, when they smile, they have a skewed smile because, you know, one side of the facial nerve is damaged.

So those kids come into the outpatient clinic much, many years down the road and I was thinking, okay, with the name of, Surviving with the name of breathing when they were babies. We had to do jaw destruction surgery, but They have to deal with all these consequences down the road, so if there is any way we can prevent all of it.

So that was the reason I started to get more interested in this, doing [00:05:00] more non invasive early on, if we really don't have to. Nice. And how does your system work? My system is that it actually scoops the tongue out of the airway. Oh. Meaning, I don't control the jawbone at all. Because the primary goal is getting rid of the tongue from the airway.

So when the device goes in, it directly scoops the tongue out of the airway, so the baby can breathe immediately. Oh. And when the tongue comes forward, the What happens is, the muscular connection between the tongue and the anterior portion of the mandible brought forward as well. So, when the tongue is forward, mandible is already forward, and that gives kind of tension to the campor mandibular joint, which is the bone center of the mandible.

So that tension, I speculate that's the drive for the accelerated, uh, mandibular growth during the treatment, and even following the treatment as well.

Rachel Baker: Well, I saw a [00:06:00] photo of your first patient, a little girl named Aliana, who's totally adorable. But I gotta admit, this advice looks like the headgear that I wore in fourth grade.

How do you go about fashioning one of these? things. Did your degree come with like a minor in metalworking?

Dr. HyeRan Choo: So during dentistry and orthodontic residency, we spent a lot of time in learning materials. Oh. Um, and composite the plastics. At the same time, we spent a lot of time in learning biomechanics and biophysics and growth and development.

So with those tools, then you are very comfortable dealing with the, you know, hardware and then Chemicals, and you can come up with whatever design you can think about creating.

Rachel Baker: This is so cool. I'm thinking maybe I should have gone into dentistry. This sounds like so much fun. Well, so that little girl, your first patient was in 2019.

What improvements have [00:07:00] been made to the orthodontic airway plate, I think that's what you call it, in the last few years? The

Dr. HyeRan Choo: important thing is about this treatment is it's not like one person doing it. It is a team approach. It has to, the experts from different disciplines have to really synergistically combine their experts to make it work.

So initially, I did not have that type of rapport from different departments, but the more I do it and people get to see the changes I was able to bring in, the level of collaboration and then, you know, time sensitive effort has improved, I think overall improved the patient care as well. Excellent.

Rachel Baker: So are you planning on doing Any sort of research or taking images or anything to find out exactly how it's working?

Dr. HyeRan Choo: Oh yeah, so we are doing a three dimensional and two dimensional cephalometric analysis on the jaw growth and overall [00:08:00] craniofacial growth and airway. And then the outcome is just fantastic. We're comparing with at the age 12 months old. These babies actual treatment for this soap is about a few weeks to a few months.

So after that treatment is done, several months later, when they become 12 months old, I have a CT done, and then, so retrospectively, I'm comparing with the Healthy Controls, one year old Healthy Controls CT, with the Soap Treated Baby CT, and then when I look at it, they are almost really like airways normalized, and the jaw growth is normalized.

So it's very promising outcomes are coming. We just don't know what's the mechanism behind it. Well,

Rachel Baker: so as of September of last year, you had treated 25 babies with a 100 percent success rate. What are you thinking your next steps are going to be here?

Dr. HyeRan Choo: Next step for this program is still, it's a, it's been only like three and a half [00:09:00] and four years of, you know, it's infancy stage of the program.

And especially it requires It's very delicate collaboration from many different departments. Still we are in this stage of developing more rapport and then producing a lot of data to make this treatment more available and then aware by other professionals as well. The interdisciplinary approach comes from neonatology, otolaryngology, nursing, infant feeding, which is rehab services.

And orthodontics and plastic surgery, sleep medicine. So a lot of people who are involved. Yeah, a lot of them. Genetics as well, of course.

Rachel Baker: I'm wondering, because it's a purely Stanford program right now, and it requires, you know, so many team members, how do you [00:10:00] recreate this at other hospitals?

Dr. HyeRan Choo: I think that's going to be the biggest challenge.

Actually, last week, I was in Mayo. Mayo Clinic asked me to come and talk to their interdisciplinary team because they're really interested in this program. But you need to overcome two things. One is operational sensitivity, meaning that there is some intricacy that as an operator, the sensitivity level is different.

So that makes it difficult. challenging. Another thing is institutional resistance. I think that the institutional resistance, it has the biggest hurdle that I faced here because it's such a new concept that a lot of people don't, either not willing to try or not willing to even accept.

Rachel Baker: The babies, they have to be at a certain age, is that correct? So that you can treat them?

Dr. HyeRan Choo: Yeah, definitely within three months. They have to be very young. The sooner the better, after they're born. 

Rachel Baker: Got it. And if it doesn't take, if it doesn't [00:11:00] work, you can always do the surgery later on? 

Dr. HyeRan Choo: Within a week or so, we can tell if it's gonna work for the baby or not.

There are other surgical options always available and surgical complication rate goes down when the babies are older. So let's say if you do the same disruption surgery within the first year, complication rate is about 26%, but if you can do the surgery after one year old, complication rate goes down to close to 11%.

So delaying the surgery itself has the big value. 

Rachel Baker: Understood. All right. Well, so, uh, we're about out of time, so I want to ask our final two questions. On each episode of Scrubcast, we ask our guests these two questions. And the first one is, who is a surgeon you admire and why? Or I suppose you could choose a dentist.

Dr. HyeRan Choo: Yeah. Dr. Park, he was my mentor and still is. [00:12:00] He was the one, actually, who told me that, Hey, Harron, um, I don't think you're gonna do well in, in Korea. You should think about going outside country. So that's, he, um, he is one of the, uh, most, uh, skilled and also deepest understanding about human being, about why, who we are, and why we are here.

Kind of very philosophical understandings about humans, and then, which motivated me to Continue to do what I am doing for very rare, um, conditioned patients as well.

Rachel Baker: Well, and, uh, the second question is the best advice you have received in 10 words or less?

Dr. HyeRan Choo: Um, it's also from Dr. Park and he told me be grateful to be in a position that you can help others.

Rachel Baker: Aww, that's really sweet. I love that. It has been [00:13:00] a pleasure talking to you. Thank you so much for coming on the show.

And that brings us to the end of another episode. If you like Scrub Cast, we hope you'll tell your friends and subscribe wherever you get your podcasts. Scrub Cast is a production of Stanford University's Department of Surgery. Today's episode was produced by Rachel Baker. The music is by Midnight Rounds and our chair is Dr. Mary Hawn.