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Andrew LM, Sandler CB, Long CA, Bauman NM, Mudd PA. Exploring Mental Health in a Pediatric Paradoxical Vocal Fold Motion Sample Using Patient-Reported Outcomes. Otolaryngol Head Neck Surg 2024; 170:1167-1172. [PMID: 38193359 DOI: 10.1002/ohn.641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 12/15/2023] [Accepted: 12/17/2023] [Indexed: 01/10/2024]
Abstract
OBJECTIVE Paradoxical vocal fold motion (PVFM) is characterized by inappropriate adduction of vocal folds during inspiration causing dyspnea. While anxiety is suspected to be a predisposing factor, incidence has been understudied. STUDY DESIGNS Retrospective review. SETTING Multidisciplinary PVFM hospital clinic. METHODS We used patient-reported outcome measures to examine anxiety and depression in consecutive patients aged 10 to 17 years using Pediatric SFv1.1 Anxiety 8b and Level 2-Depression inventories (parents completed proxy forms). T-scores were classified as normal (none to slight <55) or elevated (mild 55-59.9, moderate 60-69.9, severe >70). RESULTS Twenty-three pediatric patients and 20 parents completed surveys. Mean age was 13.74 years. For anxiety, 69.6% of patients and 40% of parents identified elevated levels. For depression, 30.4% of patients and 15% of parents identified elevated levels. Therapy need for the sample was 65.2% (34.8% active in services and 30.4% referred). Child anxiety scores were significantly higher in the therapy need group, U = 17, P = .004. CONCLUSION This study of adolescents with PVFM confirmed elevated anxiety and depression scores in 2/3 of the participants. Anxiety likely precedes diagnosis and is a predisposing factor. Referral for individualized intervention targeting anxiety and depression is indicated.
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Affiliation(s)
- Lilia Mucka Andrew
- Psychology, Children's National Hospital, George Washington University, Washington, DC, USA
| | - Claire B Sandler
- School of Medicine and Health Sciences, George Washington University, Washington, DC, USA
| | - Courtney A Long
- Hearing and Speech, Children's National Hospital, Washington, DC, USA
| | - Nancy M Bauman
- Otolaryngology, Children's National Hospital, George Washington University, Washington, DC, USA
| | - Pamela A Mudd
- Otolaryngology, Children's National Hospital, George Washington University, Washington, DC, USA
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Schonman I, Mudd PA, Ivancic R, Ryan MA, Ongkasuwan J, Prager J, Smith ME, Goudy SL, Rana MS, Wiet GJ, Bauman NM. Multi-Institutional Study of Patient-Reported Outcomes of Paradoxical Vocal Fold Motion. Laryngoscope 2023; 133:970-976. [PMID: 35730686 DOI: 10.1002/lary.30256] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/11/2022] [Accepted: 05/23/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To explore patient-reported outcome measures of pediatric paradoxical vocal fold motion through a multi-institutional study of geographically diverse United States medical facilities to assess long-term management and outcomes. METHODS Eligible participants >8 years of age diagnosed with PVFM over a 10-year period from 7 tertiary pediatric hospitals were invited to complete a survey addressing study objectives. RESULTS 65 participants completed the survey, of whom 80% were female, 75% reported a 3.5 grade point average or better, and 75% identified as competitive athletes or extremely athletic individuals. Participants rated their perceived efficacy of 13 specific treatments. Only five treatments were considered effective by a majority of the participants who tried them. The treatments that participants tried most often were breathing exercises (89.2%), bronchodilator treatments (45%), and allergy medications (35.4%). 78.8% of participants reported receiving more than one treatment and 25% reported receiving a combination of bronchodilators, anticholinergics, and steroids. At the time of PVFM diagnosis, 38% of participants had no idea when their symptoms would completely resolve. 23.3% of participants did not experience symptom resolution until greater than 1 year after diagnosis. CONCLUSIONS Traditional management tools such as breathing exercises and biofeedback treatments may not provide the long-term benefit that providers anticipate. In addition to these commonly used management strategies, highly efficacious techniques such as counseling and lifestyle management should be incorporated into the long-term management of patients whose symptoms are refractory to traditional care. LEVEL OF EVIDENCE 4 Laryngoscope, 133:970-976, 2023.
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Affiliation(s)
- Ian Schonman
- GW School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Pamela A Mudd
- Department of Otolaryngology, Children's National Health System, Washington, District of Columbia, USA
| | - Ryan Ivancic
- Department of Otolaryngology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Marisa A Ryan
- Department of Otolaryngology, Johns Hopkins Children's Center, Baltimore, Maryland, USA
| | - Julina Ongkasuwan
- Department of Otolaryngology, Texas Children's Hospital, Houston, Texas, USA
| | - Jeremy Prager
- Department of Otolaryngology, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Marshall E Smith
- Department of Otolaryngology, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Steven L Goudy
- Department of Otolaryngology, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Md Sohel Rana
- Department of Otolaryngology, Children's National Health System, Washington, District of Columbia, USA
| | - Gregory J Wiet
- Department of Otolaryngology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Nancy M Bauman
- Department of Otolaryngology, Children's National Health System, Washington, District of Columbia, USA
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Hakimi AA, Orobello NC, Mudd PA. A Nearly Obstructive Intratracheal Mass in a Pediatric Patient. JAMA Otolaryngol Head Neck Surg 2023; 149:368-369. [PMID: 36729472 DOI: 10.1001/jamaoto.2022.4908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A 12-year-old girl presented to the clinic with a 3-month history of intermittent stridor; her symptoms were initially most prominent while playing sports and were suspected to be due to asthma or seasonal allergies. What is your diagnosis?
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Affiliation(s)
- Amir A Hakimi
- Department of Otolaryngology-Head and Neck Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Nicklas C Orobello
- Department of Otolaryngology, Children's National Medical Center, Washington, DC
| | - Pamela A Mudd
- Department of Otolaryngology, Children's National Medical Center, Washington, DC
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Abstract
Vocal cord paralysis is a common cause of respiratory and feeding problems in the pediatric population. While the causes of vocal cord paralysis are multiple, iatrogenic injury of the recurrent laryngeal nerve after cardiovascular surgery is the most frequent cause. Vocal cord paralysis increases the risk of swallowing dysfunction, tracheal aspiration and pneumonia. It also increases the need for nasoenteric feeds and gastrostomy tube placement. Flexible nasopharyngolaryngoscopy is considered the gold standard for diagnosing vocal cord paralysis, but it has significant drawbacks: it is uncomfortable, it can trigger a cardiovascular event in children with unstable cardiovascular status, it can be challenging to perform, and it can be difficult to interpret. Laryngeal US has become a popular imaging modality to evaluate the function of the vocal cords. Laryngeal US is well-tolerated, easy to perform, simple to interpret and has a lower physiological impact compared to flexible nasopharyngolaryngoscopy. Laryngeal US is an accurate and low-cost diagnostic test for vocal cord paralysis. In this review, we describe the anatomy of the larynx and recurrent laryngeal nerve; the causes, symptoms and pathophysiology of vocal cord paralysis; laryngeal US technique; diagnostic criteria for vocal cord paralysis; and a reporting system.
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Affiliation(s)
- Ramon Sanchez-Jacob
- George Washington School of Medicine, Washington, DC, USA. .,Department of Radiology and Medical Imaging, Children's National Hospital, 111 Michigan Ave. NW, Washington, DC, 20015, USA.
| | - Tara K Cielma
- Department of Radiology and Medical Imaging, Children's National Hospital, 111 Michigan Ave. NW, Washington, DC, 20015, USA
| | - Pamela A Mudd
- George Washington School of Medicine, Washington, DC, USA.,Department of Otolaryngology, Children's National Hospital, Washington, DC, USA
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Wikner EE, Mulcahy CF, Gitman L, Mudd PA. A 15-year-old with a Slowly Enlarging Submental Mass. Pediatr Rev 2020; 41:S50-S53. [PMID: 33004582 DOI: 10.1542/pir.2018-0127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | - Collin F Mulcahy
- Division of Otolaryngology, Head and Neck Surgery, Department of Surgery, George Washington University, Washington, DC.,Department of Pediatric Otolaryngology, Children's National Medical Center, Washington, DC
| | - Lyuba Gitman
- Department of Pediatric Otolaryngology, Children's National Medical Center, Washington, DC
| | - Pamela A Mudd
- Department of Pediatric Otolaryngology, Children's National Medical Center, Washington, DC
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Manthiram K, Preite S, Dedeoglu F, Demir S, Ozen S, Edwards KM, Lapidus S, Katz AE, Feder HM, Lawton M, Licameli GR, Wright PF, Le J, Barron KS, Ombrello AK, Barham B, Romeo T, Jones A, Srinivasalu H, Mudd PA, DeBiasi RL, Gül A, Marshall GS, Jones OY, Chandrasekharappa SC, Stepanovskiy Y, Ferguson PJ, Schwartzberg PL, Remmers EF, Kastner DL. Common genetic susceptibility loci link PFAPA syndrome, Behçet's disease, and recurrent aphthous stomatitis. Proc Natl Acad Sci U S A 2020; 117:14405-14411. [PMID: 32518111 PMCID: PMC7322016 DOI: 10.1073/pnas.2002051117] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is the most common periodic fever syndrome in children. The disease appears to cluster in families, but the pathogenesis is unknown. We queried two European-American cohorts and one Turkish cohort (total n = 231) of individuals with PFAPA for common variants previously associated with two other oropharyngeal ulcerative disorders, Behçet's disease and recurrent aphthous stomatitis. In a metaanalysis, we found that a variant upstream of IL12A (rs17753641) is strongly associated with PFAPA (OR 2.13, P = 6 × 10-9). We demonstrated that monocytes from individuals who are heterozygous or homozygous for this risk allele produce significantly higher levels of IL-12p70 upon IFN-γ and LPS stimulation than those from individuals without the risk allele. We also found that variants near STAT4, IL10, and CCR1-CCR3 were significant susceptibility loci for PFAPA, suggesting that the pathogenesis of PFAPA involves abnormal antigen-presenting cell function and T cell activity and polarization, thereby implicating both innate and adaptive immune responses at the oropharyngeal mucosa. Our results illustrate genetic similarities among recurrent aphthous stomatitis, PFAPA, and Behçet's disease, placing these disorders on a common spectrum, with recurrent aphthous stomatitis on the mild end, Behçet's disease on the severe end, and PFAPA intermediate. We propose naming these disorders Behçet's spectrum disorders to highlight their relationship. HLA alleles may be factors that influence phenotypes along this spectrum as we found new class I and II HLA associations for PFAPA distinct from Behçet's disease and recurrent aphthous stomatitis.
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Affiliation(s)
- Kalpana Manthiram
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892;
| | - Silvia Preite
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892
| | - Fatma Dedeoglu
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115
| | - Selcan Demir
- Department of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, 06100 Ankara, Turkey
| | - Seza Ozen
- Department of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, 06100 Ankara, Turkey
| | - Kathryn M Edwards
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN 37232
| | - Sivia Lapidus
- Division of Pediatric Rheumatology, Joseph M. Sanzari Children's Hospital, Hackensack Meridian Health, Hackensack, NJ 07601
| | - Alexander E Katz
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892
| | - Henry M Feder
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, CT 06106
| | - Maranda Lawton
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115
| | - Greg R Licameli
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115
| | - Peter F Wright
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756
| | - Julie Le
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892
| | - Karyl S Barron
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892
| | - Amanda K Ombrello
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892
| | - Beverly Barham
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892
| | - Tina Romeo
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892
| | - Anne Jones
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892
| | - Hemalatha Srinivasalu
- Division of Pediatric Rheumatology, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC 20010
| | - Pamela A Mudd
- Division of Pediatric Otolaryngology, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC 20010
| | - Roberta L DeBiasi
- Division of Pediatric Infectious Diseases, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC 20010
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC 20010
- Department of Microbiology, Immunology, and Tropical Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC 20010
| | - Ahmet Gül
- Department of Internal Medicine, Division of Rheumatology, Istanbul Faculty of Medicine, Istanbul University, 34093 Istanbul, Turkey
| | - Gary S Marshall
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY 40202
| | - Olcay Y Jones
- Division of Pediatric Rheumatology, Walter Reed National Military Medical Center, Bethesda, MD 20889
| | | | - Yuriy Stepanovskiy
- Department of Pediatric Infectious Diseases and Pediatric Immunology, Shupyk National Medical Academy of Postgraduate Education, 04112 Kiev, Ukraine
| | - Polly J Ferguson
- Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA 52242
| | - Pamela L Schwartzberg
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892
| | - Elaine F Remmers
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892
| | - Daniel L Kastner
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892;
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7
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Yibrehu B, Georgakopoulos B, Mudd PA, Rana MS, Bauman NM. Outcomes of Paradoxical Vocal Cord Motion Diagnosed in Childhood. Ann Otol Rhinol Laryngol 2020; 129:1195-1209. [PMID: 32527140 DOI: 10.1177/0003489420931894] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To explore long-term patient reported outcome (PRO) measures of pediatric paradoxical vocal cord motion (PVCM) including ease of diagnosis, management, symptom duration and effect on quality of life. METHODS All children >8 years of age diagnosed with PVCM at a tertiary pediatric hospital between 2006 and 2017 were invited to complete a survey addressing study objectives. RESULTS 21/47 eligible participants could be contacted and 18/21 (86%) participated. 78% were female with a mean age at diagnosis of 11.6 and 15.0 years at survey completion. Common PVCM symptoms reported were dyspnea (89%), globus sensation (56%), and stridor (50%). The median time to diagnosis was 3 months (IQR 2-5 months). Nearly all reported being misdiagnosed with another condition, usually asthma, until being correctly diagnosed usually by an otolaryngologist. Participants reported undergoing 3.7 diagnostic studies (range 0-8); pulmonary function testing was most common. Of numerous treatments acknowledged, breathing exercises were common (89%) but only reported helpful by 56%. Use of biofeedback was recalled in 1/3 of subjects but reported helpful in only 14% of them. Anti-reflux, allergy, anticholinergics, inhalers and steroids were each used in >50%, but rarely reported effective. PVCM was reportedly a significant stressor when initially diagnosed but despite 2/3 of participants still reporting ongoing PVCM symptoms, the perceived stress significantly decreased over time (Z = 3.26, P = 0.001). CONCLUSIONS This first PVCM PRO study endorses that diagnosis is often delayed and prescribed treatments often viewed as ineffective. While biofeedback and breathing exercises may be critical for short-term control of PVCM episodes, lifestyle changes and stress reduction are likely necessary for long-term management. Increased awareness and improvements in management are needed for this condition.
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Affiliation(s)
- Betel Yibrehu
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Bianca Georgakopoulos
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Pamela A Mudd
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,Children's National Hospital, Washington, DC, USA
| | | | - Nancy M Bauman
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,Children's National Hospital, Washington, DC, USA
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Lewis RJ, Mandler AG, Perez G, Mudd PA. Delayed complication of tracheocutaneous fistula closure with severe compromising subcutaneous emphysema. BMJ Case Rep 2019; 12:12/6/e229526. [PMID: 31229983 DOI: 10.1136/bcr-2019-229526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We report a significant complication after tracheocutaneous fistula (TCF) excision with closure by secondary intention in a 4-year-old boy who had been tracheostomy dependent since infancy. He had a persistent 3 mm TCF one year after decannulation. On postoperative day 2 the patient developed profound subcutaneous emphysema and pneumomediastinum. He was extubated after 2 days and discharged from the hospital on postoperative day 7. At follow up he had complete resolution of subcutaneous emphysema and complete closure of the TCF. The main methods of TCF closure and management of subcutaneous emphysema are discussed along with the lessons learned from this case.
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Affiliation(s)
- Robert J Lewis
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Ari G Mandler
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Geovanny Perez
- Division of Pulmonary Medicine, Children's National Health System, Washington, DC, USA.,Department of Pediatrics, Pulmonary Medicine, and Integrative Systems Biology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Pamela A Mudd
- Division of Pediatric Otolaryngology, Children's National Health System, Washington, DC, USA.,Department of Pediatrics and Sugery, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Straughan AJ, Mudd PA, Silva AL, Callicott SS, Krakovsky G, Bauman NM. Cost Analysis of a Multidisciplinary Vascular Anomaly Clinic. Ann Otol Rhinol Laryngol 2019; 128:401-405. [DOI: 10.1177/0003489419826135] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: Multidisciplinary vascular anomaly clinics (VACs) offer important value to pediatric patients with complex vascular anomalies whose care overlaps specialties. These clinics are labor intensive and costly to operate since providers see fewer patients compared to their individual specialty clinic. Our North American tertiary care institution’s VAC specialists include a pediatric otolaryngologist, pediatric surgeon, pediatric plastic surgeon, pediatric dermatologist, and interventional radiologist. To assess financial feasibility, we conducted a cost analysis of our VACs comprised of 2 half-day multidisciplinary physician attended clinics (5 specialists at our main campus and 2 specialists at a satellite clinic) and a half-day nurse practitioner clinic. Method: Assessment of net revenue based on net collections for clinic, professional, operative, hospital setting, and facility charges generated during 12 consecutive monthly VACs beginning July 1, 2015. Expense calculations included provider and staff salaries, benefits, supply costs, and clinic leasing costs. Results: There were 469 clinic visits, of which 202 were new patient evaluations. Sixty-eight patients underwent 93 procedures under general anesthesia, including procedures performed by our interventional radiologist, most commonly sclerotherapy or embolization (n = 37), surgical interventions including endoscopy (n = 36), or laser procedures (n = 20). Three patients were admitted. Fifty-seven patients received a new diagnosis different from that for which they were referred. Gross revenue was $1 810 525, and net revenue was 42.5%, or $783 152. Expenses totaled $453 415 for a net positive revenue of $329 737. Conclusion: When including direct downstream revenue, particularly from operative procedures, our VAC program operates on a net positive margin, making the program financially feasible.
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Affiliation(s)
| | - Pamela A. Mudd
- Children’s National Health System, Washington, DC, USA
- George Washington University School of Medicine, Washington, DC, USA
| | | | | | | | - Nancy M. Bauman
- Children’s National Health System, Washington, DC, USA
- George Washington University School of Medicine, Washington, DC, USA
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Affiliation(s)
- Collin F Mulcahy
- Division of Otolaryngology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Srijaya K Reddy
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Health System, Washington, DC, USA
| | - Emily E Wikner
- School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Pamela A Mudd
- Division of Otolaryngology, Children's National Health System, Washington, DC, USA
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11
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Mudd PA, Thottathil P, Giordano T, Wetmore RF, Elden L, Jawad AF, Ahumada L, Gálvez JA. Association Between Ibuprofen Use and Severity of Surgically Managed Posttonsillectomy Hemorrhage. JAMA Otolaryngol Head Neck Surg 2017; 143:712-717. [PMID: 28472239 DOI: 10.1001/jamaoto.2016.3839] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Ibuprofen used in postoperative management of pain after tonsillectomy has not been shown to increase the overall risk for posttonsillectomy hemorrhage (PTH). The severity of bleeding is difficult to quantify but may be a more important outcome to measure. Objective To evaluate the association between ibuprofen use and severity of PTH using transfusion events as a marker of severity. Design, Setting, and Participants This retrospective cohort study identified 8868 patients who underwent tonsillectomy from January 20, 2011, through June 30, 2014, at the tertiary academic Children's Hospital of Philadelphia. Of these patients, 6710 met the inclusion criteria. Data were collected using electronic database acquisition and query. Main Outcomes and Measures Multivariate analysis was performed to identify independent prognostic factors for PTH and receipt of transfusion. Results Of the 6710 patients who met criteria for analysis (3454 male [51.5%] and 3256 female [48.5%]; median age, 5.4 years [interquartile range, 3.7-8.2 years]), 222 (3.3%) presented with PTH that required surgical control (sPTH). A total of 15 of the 8868 patients required transfusion for an overall risk for transfusion after tonsillectomy of 0.2%. Fifteen of 222 patients undergoing sPTH (6.8%) received transfusions. No significant independent increased risk for sPTH was associated with use of ibuprofen (adjusted odds ratio [OR], 0.90; 95% CI, 0.68-1.19). A significant independent association was found in the risk for sPTH in patients 12 years or older (adjusted OR, 2.74; 95% CI, 1.99-3.76) and in patients with a history of recurrent tonsillitis (adjusted OR, 1.52; 95% CI, 1.12-2.06). When using transfusion rates as a surrogate for severity of sPTH, transfusion increased by more than 3-fold among ibuprofen users compared with nonusers (adjusted OR, 3.16; 95% CI, 1.01-9.91), and the upper limit of the 95% CI suggests the difference could be nearly 10 times greater. Conclusions and Relevance The risk for sPTH is not increased with use of postoperative ibuprofen but is increased in patients 12 years or older and patients undergoing tonsillectomy with a history of recurrent tonsillitis. Hemorrhage severity is significantly increased with ibuprofen use when using transfusion rate as a surrogate marker for severity.
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Affiliation(s)
- Pamela A Mudd
- School of Medicine and Health Sciences, George Washington University, Washington, DC2Division of Pediatric Otolaryngology, Children's National Medical Center, Washington, DC
| | - Princy Thottathil
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania4Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Terri Giordano
- Division of Otolaryngology (Ear, Nose, and Throat), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ralph F Wetmore
- Division of Otolaryngology (Ear, Nose, and Throat), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania6Department of Otorhinolaryngology-Head and Neck Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lisa Elden
- Division of Otolaryngology (Ear, Nose, and Throat), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania6Department of Otorhinolaryngology-Head and Neck Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Abbas F Jawad
- Department of Biostatistics in Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Luis Ahumada
- Enterprise Reporting and Analytics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 9Section of Biomedical Informatics, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jorge A Gálvez
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania4Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia9Section of Biomedical Informatics, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 10Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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12
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Mudd PA, Silva AL, Callicott SS, Bauman NM. Cost Analysis of a Multidisciplinary Aerodigestive Clinic: Are Such Clinics Financially Feasible? Ann Otol Rhinol Laryngol 2017; 126:401-406. [DOI: 10.1177/0003489417699420] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: Multidisciplinary clinics offer important value to pediatric patients with complex conditions that overlap specialties; however, such labor-intensive clinics are difficult to facilitate. We performed a cost analysis of our pediatric multidisciplinary aerodigestive clinic (MADC) to assess its financial feasibility at our tertiary care institution. Method: Revenue was based on net collections for clinic, professional, and hospital setting charges generated during 12 consecutive monthly MADCs beginning August 2013. Clinic charges included facility and speech pathologist fees. Professional charges included clinic and operative fees generated by providers and anesthesiologist. Hospital setting fees included facility and material charges for technical procedures. Direct expense calculations included all providers and staff salaries, benefits, and supply costs. Results: Charge capture for 54 consecutive patients seen during the study time included new visits 99203-99205 (n = 63), consults 99243-99245 (n = 60), and follow-up visits 99212-99215 (n = 196). Sixty percent of patients underwent a clinic nasopharyngeal or laryngeal endoscopy (92511 or 31575), and 60% underwent subsequent intraoperative procedures with 1 (n = 8) or 2 to 3 services (n = 24). Program net revenue totaled $828 136 and direct costs $518 867, accounting for a net positive margin of $309 269. Conclusions: When including direct downstream revenue, our MADC operates on a net positive margin, making it financially feasible.
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Affiliation(s)
- Pamela A. Mudd
- Department of Otolaryngology, Head and Neck Surgery, Children’s National Health Services, Washington, DC, USA
| | - Allison L. Silva
- Joseph E. Roberts, Jr. Center for Surgical Care, Children’s National Health Services, Washington, DC, USA
| | - Susan S. Callicott
- Joseph E. Roberts, Jr. Center for Surgical Care, Children’s National Health Services, Washington, DC, USA
| | - Nancy M. Bauman
- Department of Otolaryngology, Head and Neck Surgery, Children’s National Health Services, Washington, DC, USA
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Kennedy WP, Mudd PA, Maguire MA, Souders MC, McDonald-McGinn DM, Marcus CL, Zackai EH, Solot CB, Mason TBA, Jackson OA, Elden LM. 22q11.2 Deletion syndrome and obstructive sleep apnea. Int J Pediatr Otorhinolaryngol 2014; 78:1360-4. [PMID: 24958162 DOI: 10.1016/j.ijporl.2014.05.031] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 05/23/2014] [Accepted: 05/25/2014] [Indexed: 10/25/2022]
Abstract
UNLABELLED Otolaryngologic problems are common in the 22q11.2 deletion syndrome (DS) population. Structural anomalies and retrognathia may predispose these patients to obstructive sleep apnea (OSA). The current association of OSA in this population is not defined. OBJECTIVE (1) Define the frequency of OSA in 22q11.2 DS patients referred for polysomnography (PSG). (2) Determine if OSA is present before and/or after surgery to correct velopharyngeal insufficiency (VPI). (3) Determine effect of prior adenotonsillectomy on OSA following VPI surgery. METHODS Retrospective review of children treated from 2006 to 2013 in a tertiary care setting identified by ICD-9 758.32 (velocardiofacial syndrome) and 279.11 (DiGeorge syndrome). Surgical history and PSG data were abstracted from the identified records. RESULTS We identified 323 patients with 22q11.2 DS; 57 (18%) were screened at any point in care using PSG and 15 patients had PSG at multiple time points in care. In most cases, indication for PSG was sleep disordered breathing or pre-operative planning. Overall, 33 patients met criteria for OSA on PSG, accounting for 10.2% of our study population; however, the percentage of patients with OSA was significantly higher within the group of 57 patients (58%) who were screened with PSG. Twenty-one of the screened patients (54%) had PSG prior to any pharyngeal surgery and had mild to severe OSA (obstructive apnea/hypopnea index (AHI): median 5.1/h, range 1.9-25.6). Eighteen patients had PSG after adenotonsillectomy; 8 of these patients (44%) had mild to moderate OSA (median AHI 2.95/h, range 1.9-5.4). Seventeen patients had PSG after VPI surgery (palatopharyngeal flap (PPF) n=16, sphincteroplasty n=1). Nine of these patients (53%) had mild to severe OSA (median AHI 3/h, range 1.9-15). Patients who underwent adenotonsillectomy prior to VPI surgery had similar prevalence of OSA (50%, n=12) than those who did not (OSA: 60%, n=5, p=0.70). Most children had mild OSA. CONCLUSION Prevalence of OSA in this population of 22q11.2 DS patients is higher than expected in the general population. OSA risk is highest after VPI surgery, and may be decreased by adenotonsillectomy. Providers should have awareness of increased prevalence of OSA in patients with 22q11.2 DS. Close monitoring for OSA is warranted given the likelihood of subsequent surgical intervention that can worsen OSA.
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Affiliation(s)
- William P Kennedy
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, United States.
| | - Pamela A Mudd
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Meg A Maguire
- Division of Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Margaret C Souders
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Donna M McDonald-McGinn
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Carole L Marcus
- Division of Pulmonary Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Elaine H Zackai
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Cynthia B Solot
- Division of Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | | | - Oksana A Jackson
- Division of Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Lisa M Elden
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
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Fountain CR, Mudd PA, Ramakrishnan VR, Sillau SH, Kingdom TT, Katial RK. Characterization and treatment of patients with chronic rhinosinusitis and nasal polyps. Ann Allergy Asthma Immunol 2013; 111:337-41. [PMID: 24125137 DOI: 10.1016/j.anai.2013.07.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 07/10/2013] [Accepted: 07/13/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with chronic rhinosinusitis (CRS) and nasal polyps (NPs) may be subdivided into aspirin-sensitive (AS) and aspirin-tolerant (AT) populations. These cohorts are not well characterized. OBJECTIVE To examine phenotypic characteristics and determine the extent of medical/surgical interventions in patients with CRS+NP and to compare the AS with the AT subset in the CRS+NP sample. METHODS Retrospective chart review was performed at a tertiary academic respiratory hospital. Data included patient demographics, asthma severity, peripheral eosinophilia, Lund-Mackay computed tomographic score, symptomatic dysosmia, and therapeutic interventions. RESULTS Of the 182 patients included, 81 had aspirin sensitivity (45%) and 101 had aspirin tolerance (55%). Asthma was present in 94% of patients with CRS+NP (100% in AS subgroup vs 89% in AT subgroup, P = .001). Eighty-eight percent of the CRS+NP sample had moderate to severe persistent asthma. In the AS and AT subgroups, asthma severity was similar (P > .6). The CRS+NP sample showed a mean computed tomographic score of 14.0 (44% with eosinophilia and 46% with dysosmia). More severe sinus disease was noted in the AS group (Lund-Mackay computed tomographic scores, P = .002; olfactory symptoms, P = .001). Serum eosinophil levels were not statistically different between groups (51% in AS group, 39% in AT group, P > .1). CONCLUSION This study is one of the broadest reviews of patients with CRS+NP, with unique findings in the high prevalence of asthma in AS and AT patients, greater olfactory dysfunction in AS patients, and a minority of patients with CRS+NP and circulating eosinophils. Most AS patients do not have increased circulating eosinophils, as is often believed. These results shed further light on the association between asthma and upper respiratory tract disease in those with nasal polyposis.
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Abstract
Objective. To determine benefits of early intervention in neonates with symptomatic micrognathia who underwent bilateral mandibular distraction osteogenesis within the first 90 days of life as relates to growth, need for supportive care, and further invasive procedures. Study Design. Case series with chart review. Setting. Tertiary care, academic children’s hospital. Subjects and Methods. Review of neonates with symptomatic micrognathia who underwent bilateral mandibular distraction osteogenesis in the past 5 years. Inclusion criteria included mandibular distraction osteogenesis performed within the first 90 days of life. Outcome measures included hospital course, growth curves, supportive home care needs, and airway at cleft repair. Results. Twenty-four patients met inclusion criteria. The mean age at distraction was 30 days, and the average discharge was postoperative day 14. One patient required home oxygen, 50% were able to feed exclusively by oral diet, and no patients required tracheotomy. In addition, airway results were substantial, with 90% of patients showing objective improvement in airway grade from time of mandibular distraction to time of cleft repair. Conclusion. We present our initial outcomes on mandibular distraction osteogenesis in neonates with symptomatic micrognathia. Early intervention allows discharge to home with minimal supportive care needs by avoiding tracheostomy and facilitating transition to oral feeds. The airway improvement is significant and is sustained and allows for easier intubation at time of cleft repair.
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Affiliation(s)
- Pamela A. Mudd
- Department of Pediatric Otolaryngology, Children’s Hospital Colorado, Aurora, Colorado, USA
- Department of Otolaryngology, University of Colorado–Denver School of Medicine, Aurora, Colorado, USA
| | - Jonathan N. Perkins
- Department of Pediatric Otolaryngology, Children’s Hospital Colorado, Aurora, Colorado, USA
- Department of Otolaryngology, University of Colorado–Denver School of Medicine, Aurora, Colorado, USA
| | - Jeri E. F. Harwood
- Department of Pediatrics, University of Colorado–Denver School of Medicine, Aurora, Colorado, USA
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado–Denver, Aurora, Colorado, USA
| | - Sondra Valdez
- Department of Pediatric Otolaryngology, Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Gregory C. Allen
- Department of Pediatric Otolaryngology, Children’s Hospital Colorado, Aurora, Colorado, USA
- Department of Otolaryngology, University of Colorado–Denver School of Medicine, Aurora, Colorado, USA
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Mudd PA, Katial RK, Alam R, Hohensee S, Ramakrishnan V, Kingdom TT. Variations in expression of matrix metalloproteinase-9 and tissue inhibitor of metalloproteinase-1 in nasal mucosa of aspirin-sensitive versus aspirin-tolerant patients with nasal polyposis. Ann Allergy Asthma Immunol 2011; 107:353-9. [PMID: 21962096 DOI: 10.1016/j.anai.2011.07.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Revised: 06/16/2011] [Accepted: 07/29/2011] [Indexed: 11/28/2022]
Abstract
BACKGROUND Matrix metalloproteinases (MMPs) are key enzymes responsible for extracellular matrix degradation contributing to the progressive histological changes seen in lower airway disease, including asthma. MMP-9 and TIMP-1 have also shown some role in the pathogenesis of chronic rhinosinusitis (CRS) and nasal polyposis (NP). OBJECTIVE We aim to determine variability in expression of MMP-9 and its inhibitor, tissue inhibitor of metalloproteinase-1 (TIMP-1), in sinus tissue from distinct patient populations presenting with nasal polyposis. METHODS The expression of MMP-9 and TIMP-1 was investigated in nasal polyp tissue from 6 aspirin-sensitive (AS) and 6 aspirin-tolerant (AT) patients undergoing endoscopic sinus surgery for chronic rhinosinusitis with nasal polyposis (CRSwNP). Sinus mucosa from 6 patients with chronic rhinosinusitis without nasal polyposis (CRSsNP) was used as control. The MMP-9 and TIMP-1 expression was measured using immunofluorescence technique and graded using manual and computerized methods. RESULTS Expression of TIMP-1 was significantly reduced in the AS group when compared with both the AT and CRSsNP (control) groups (P < .001). The MMP-9/TIMP-1 ratio was significantly increased in the AS group when compared with other patient groups (P < .001). The MMP- 9 expression was similar between study and control groups. CONCLUSION These results support the importance of MMP-9 and TIMP-1 expression in nasal polyp formation. The decreased expression of TIMP-1 in AS patients may promote the effects of MMP-9 expression and thus contribute to tissue remodeling and inflammatory changes. This finding may lead to further understanding of disease severity and resistance to treatment in this group of patients, as well as the pathogenesis of nasal polyps.
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Affiliation(s)
- Pamela A Mudd
- University of Colorado, Department of Otolaryngology, Aurora, 80045, USA
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Scapa VI, Ramakrishnan VR, Mudd PA, Kingdom TT. Upregulation of RANTES in nasal polyps from patients with cystic fibrosis. Int Forum Allergy Rhinol 2011; 1:157-60. [DOI: 10.1002/alr.20027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Revised: 08/25/2010] [Accepted: 10/11/2010] [Indexed: 11/10/2022]
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Abstract
CD4+CD25+ regulatory T cells (Treg) constitute an important mechanism of peripheral immune tolerance. Organ-specific autoimmune conditions, such as thyroiditis and insulin-dependent diabetes mellitus have been attributed to a breakdown of this tolerance mechanism. However, this T-cell subset has not been well studied in patients and mice with systemic lupus erythematosus (SLE; lupus). The information that has been gathered so far using new tools that discriminate Treg from activated T cells indicates that reduced numbers of Treg may exist in patients with lupus. In addition, potential defects in SLE Treg function have been documented in humans and mice. Our group has demonstrated equivalent proportions of thymic Treg in lupus prone and normal mice. We therefore propose that Treg function in SLE is the more important factor to address in future studies of murine lupus. Recent studies have shown that Toll-like receptor (TLR) ligation can result in an abrogation of Treg-mediated suppression; specifically ligation of TLR-2, -4, -8 and -9. We address this new information about TLRs and Treg and propose a model for Treg tolerance breakdown to nucleic acid-binding SLE autoantigens.
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Affiliation(s)
- P A Mudd
- Arthritis and Immunology Research Program, Oklahoma Medical Research Foundation, 825 N.E. 13th Street, Oklahoma City, OK 73104, USA
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