What I find incredibly difficult to accept is the idea that every child with an airway problem should automatically “start in the medical system” when that system often does not measure the entire system, does not establish whether the child has adequate age-related craniofacial capacity, and does not even offer some of the structural interventions that could potentially address the underlying deficiency.
That is a massive problem.
If a child has developed inside a craniofacial system that is undersized, structurally constrained, or lacking adequate capacity, then many of the things being treated medically may be downstream consequences of that larger problem.
Yet instead of first asking whether the system itself is deficient, we often move directly toward treating the individual parts inside it.
- We shrink turbinates.
- We remove tonsils and adenoids.
- We medicate inflammation.
- We address nasal obstruction.
- We perform procedures on individual tissues.
Some of those treatments may absolutely be necessary.
But how can we know the appropriate treatment hierarchy if we never first establish whether the entire craniofacial system developed with adequate capacity?
Thinking About the Entire System
Think about how we would approach this in almost any other complex system.
Imagine NASA sends a rocket into space and one component begins malfunctioning. Would the first response simply be, “That component is the problem—replace it”?
Or would engineers first ask how the entire system is functioning?
They would want to understand whether the failing component is truly defective on its own or whether it is being forced to operate outside its intended conditions because of a larger systems problem—pressure, temperature, vibration, fuel delivery, electrical load, software, structural forces, or interactions with another subsystem.
In a complex system, the component that fails is not necessarily the component that caused the failure.
Replacing the part without understanding the environment in which it failed could leave the underlying problem untouched. The new component could fail again, another component could become overloaded, or the system could continue functioning inefficiently because the true source of the problem was never addressed.
That is basic systems thinking.
You evaluate the system first, understand how the components interact within it, and then determine whether a particular component needs to be repaired, modified, or replaced.
Applying Systems Thinking to Airway Care
That is the part I struggle with in airway care.
If we would never troubleshoot a rocket, aircraft, automobile, or virtually any other complex engineered system by immediately modifying the symptomatic component without first understanding the larger system’s operating conditions, why would we accept that approach in something as complex as a developing human airway?
Clinicians recognize that skeletal deficiency exists, that expansion can influence airway dimensions and oral volume, and that measurable craniofacial growth parameters exist. Yet those measurements are still not routinely incorporated into the medical pathway, and structural treatment frequently sits outside that pathway.
The system ends up doing exactly what it is designed to do:
It treats the parts it measures with the treatments it has access to.
But that does not necessarily mean it is treating the primary problem.
If you never measure whether the container is too small, and you do not have the ability to enlarge the container, there is a risk that you will keep modifying the contents of the container instead.
That is what concerns me.
In some children, we may be clipping, shrinking, removing, or medicating downstream structures without determining whether restoring capacity upstream could have changed the need for those interventions.
To me, that is not a truly comprehensive model of airway care.
Two Questions a Comprehensive Model Should Ask
What is obstructing or malfunctioning inside this child’s airway?
Did this child develop enough craniofacial and airway capacity in the first place?
If you only ask the first question, you are evaluating components.
If you ask both, you are evaluating the system.
The lesson from systems engineering is simple: a malfunctioning component should never automatically be assumed to be the root cause. First understand the system that component is being asked to function within. Then decide what actually needs to be treated.
