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Cost Analysis of Channeled, Distal Chip Laryngoscope for In-office Laryngopharyngeal Biopsies
Marcus, Sonya; Timen, Micah; Dion, Gregory R; Fritz, Mark A; Branski, Ryan C; Amin, Milan R
OBJECTIVE:Given that financial considerations play an increasingly prominent role in clinical decision-making, we sought (1) to determine the cost-effectiveness of in-office biopsy for the patient, the provider, and the health-care system, and (2) to determine the diagnostic accuracy of in-office biopsy. STUDY DESIGN/METHODS:Retrospective, financial analyses were performed. METHODS:Patients who underwent in-office (Current Procedural Terminology Code 31576) or operative biopsy (CPT Code 31535) for laryngopharyngeal lesions were included. Two financial analyses were performed: (1) the average cost of operating room (OR) versus in-office biopsy was calculated, and (2) a break-even analysis was calculated to determine the cost-effectiveness of in-office biopsy for the provider. In addition, the diagnostic accuracy of in-office biopsies and need for additional biopsies or procedures was recorded. RESULTS:Of the 48 patients included in the current study, 28 underwent in-office biopsy. A pathologic sample was obtained in 26 of 28 (92.9%) biopsies performed in the office. Of these patients, 16 avoided subsequent OR procedures. The average per patient cost was $7000 and $11,000 for in-office and OR biopsy, respectively. Break-even analysis demonstrated that the provider could achieve a profit 2 years after purchase of the necessary equipment. CONCLUSION/CONCLUSIONS:In-office laryngopharyngeal biopsies are accurate and, overall, more cost-effective than OR biopsies. Purchase of the channeled, distal chip laryngoscope and biopsy forceps to perform in-office biopsies can be profitable for a provider with a videolaryngoscopy tower. In-office biopsy should be considered the initial diagnostic tool for suspected laryngopharyngeal malignancies noted on videolaryngoscopy.
PMID: 29472150
ISSN: 1873-4588
CID: 2963902
Adverse Events after Rigid and Flexible Endoscopic Repair of Zenker's Diverticula: A Systematic Review and Meta-analysis
Crawley, Brianna; Dehom, Salem; Tamares, Shanalee; Marghalani, Abdullah; Ongkasuwan, Julina; Reder, Lindsay; Ivey, Chandra; Amin, Milan; Fritz, Mark; Pitman, Michael; Tulunay-Ugur, Ozlem; Weissbrod, Philip
OBJECTIVE:To determine adverse events after endoscopic flexible vs endoscopic rigid cricopharyngeal myotomy for treatment of Zenker's diverticulum (ZD). DATA SOURCES/METHODS:Systematic review of MEDLINE, Web of Science, CINAHL, Clinicaltrials.gov, and Cochrane Central Register of Controlled Trials for all years according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Additional studies were identified from review citations and a by hand search of manuscripts referencing ZD. REVIEW METHODS/METHODS:A structured literature search was conducted to identify studies for this systematic review. Methodological Index for Non-randomized Studies (MINORS) criteria were applied to assess study quality. For inclusion, each study had to provide data for at least 10 adult patients who had undergone endoscopic ZD repair reporting clear association with the postprocedure course in each case. Data extracted included all reported adverse events, recurrences, follow-up, and operative times. RESULTS:In total, 115 studies were included. All but 8 were retrospective case series. Sixty-one reported series of patients after rigid endoscopic stapler repair, 31 after rigid laser repair, and 13 with other rigid endoscopic instruments. Twenty-nine flexible endoscopic studies were included. Mortality, infection, and perforation were not significantly more likely in either the rigid or the flexible group, but bleeding and recurrence were more likely after flexible endoscopic techniques (20% vs <10% and 4% vs 0%, respectively). Dental injury and vocal fold palsy were reported rarely in the rigid endoscopic groups. CONCLUSIONS:Adverse events are rare after endoscopic Zenker's repair. The flexible approach minimizes exposure limitations and can be completed in some patients without general anesthesia. Transoral rigid approaches result in fewer revision surgeries compared with flexible diverticulotomy.
PMID: 31010403
ISSN: 1097-6817
CID: 3821182
Automated Indentation Mapping of Vocal Fold Structure and Cover Properties Across Species
Dion, Gregory R; Lavoie, Jean-Francois; Coelho, Paulo; Amin, Milan R; Branski, Ryan C
OBJECTIVES/HYPOTHESIS/OBJECTIVE:Various animal models have been employed to investigate vocal fold (VF) and phonatory function. However, biomechanical testing techniques to characterize vocal fold structural properties vary and have not compared critical properties across species. We adapted a nondestructive, automated indentation mapping technique to simultaneously quantify VF structural properties (VF cover layer and intact VF) in commonly used species based on the hypothesis that VF biomechanical properties are largely preserved across species. STUDY DESIGN/METHODS:Ex vivo animal model. METHODS:Canine, leporine, and swine larynges (n = 4 each) were sagittally bisected, measured, and subjected to normal indentation mapping (indentation at 0.3 mm; 1.2 mm/s) with a 2-mm spherical indenter to quantify normal force along the VF cover layer, structural stiffness, and displacement at 0.8 mN; two-dimensional maps of the free VF edge through the conus elasticus were created for these characterizations. RESULTS:Structural stiffness was 7.79 gf/mm (0.15-74.55) for leporine, 2.48 gf/mm (0.20-41.75) for canine, and 1.45 gf (0.56-4.56) for swine. For each species, the lowest values were along the free VF edge (mean ± standard deviation; leporine: 0.40 ± 0.21 gf/mm, canine: 1.14 ± 0.49 gf/mm, swine: 0.89 ± 0.28 gf/mm). Similar results were obtained for the cover layer normal force at 0.3 mm. On the free VF edge, mean (standard deviation) displacement at 0.08 gf was 0.14 mm (0.05) in leporine, 0.11 mm (0.03) in canine, and 0.10 mm (0.02) in swine. CONCLUSIONS:Automated indentation mapping yielded reproducible biomechanical property measurement of the VF cover and intact VF. Divergent VF structural properties across canine, swine, and leporine species were observed. LEVEL OF EVIDENCE/METHODS:NA. Laryngoscope, 2018.
PMID: 30408175
ISSN: 1531-4995
CID: 3456172
Correlation between video fluoroscopic swallow study and laryngological clinical evaluation in patients with cough [Meeting Abstract]
Balou, M; Dion, G R; Brates, D; Amin, M
Introduction: Videofluoroscopic swallow studies (VFSS) are commonly requested by otolaryngologists to evaluate swallow function in patients with cough but no data exists on the utility of VFSS in this population. We aim to determine which history clinical exam and laryngoscopy findings correlate with abnormal VFSS findings in patients with cough.
Material(s) and Method(s): Ten items from flexible videolaryngoscopy were recorded including: motion abnormalities pooling of secretions pharyngeal asymmetry and glottal insufficiency. VFSS findings recorded included penetration aspiration delayed initiation and presence of residue after swallow. Nonparametric statistical analysis was performed to determine correlations between history and clinical exam observation and VFSS findings. A total of 405 patients with a chief complaint of cough were referred to speech language pathology. Of those 107 had a VFSS and 93 had an esophagram. Forty-five patients had a VFSS after referral and were included in the analysis.
Result(s): Age (p = 0.35) glottal insufficiency (p = 0.33) pooling of secretions (p = 0.10) any videolaryngoscopy abnormality (p = 0.07) cardiopulmonary history (p = 0.29) and other variables did not correlate VFSS abnormalities in patients with cough. Only gender (p = 0.02) was a predictor of an abnormal VFSS (86% males and 57% females).
Conclusion(s): This study found that videolaryngoscopy and clinical exam were not predictive of VFSS abnormalities in patients with cough
EMBASE:631602527
ISSN: 1432-0460
CID: 4425872
The Role of Oral Steroids in the Treatment of Phonotraumatic Vocal Fold Lesions in Women
Amin, Milan R; Achlatis, Stratos; Gherson, Shirley; Fang, Yixin; Wang, Binhuan; Born, Hayley; Branski, Ryan C; Johnson, Aaron M
Objectives (1) To determine the short-term effectiveness of oral steroids in women with benign vocal fold lesions and (2) to determine the effectiveness of adjuvant oral steroids in women undergoing voice therapy for benign vocal fold lesions. Study Design Randomized, double-blind, placebo-controlled clinical trial. Setting Tertiary voice care center. Subjects and Methods Thirty-six patients undergoing voice therapy for the treatment of phonotraumatic vocal fold lesions randomly received either a 4-day course of oral steroids or a placebo prior to initiating voice therapy. Voice Handicap Index-10 (VHI-10) scores, video and audioperceptual analyses, acoustic and aerodynamic analyses at baseline, and patient perception of improvement after a short course of steroids or a placebo and at the conclusion of voice therapy were collected. Results Thirty patients completed the study, of whom 27 (only female) were analyzed. The primary outcome measure, VHI-10, did not improve after the 4-day course of steroids or placebo. Secondary measures similarly showed no improvement with steroids relative to placebo. Voice therapy demonstrated a positive effect on both VHI-10 and patient-perceived improvement of voice in all subjects. Conclusion A short course of oral steroids did not benefit women with phonotraumatic vocal fold lesions. In addition, steroids had little beneficial effect when used adjunctively with voice therapy in this patient cohort.
PMID: 30322353
ISSN: 1097-6817
CID: 3368122
The effects of concurrent chemoradiation therapy to the base of tongue in a preclinical model
Benedict, Peter A; Ruiz, Ryan; Verma, Avanti; Dion, Gregory R; Oh, Philmo; Wang, Binhuan; Ahmed, Omar H; Hiwatashi, Nao; Bing, Renjie; Victor, Kristen; Hu, Kenneth S; Johnson, Aaron; Branski, Ryan C; Amin, Milan R
OBJECTIVES/HYPOTHESIS/OBJECTIVE:To develop a clinically relevant model of oropharyngeal concurrent chemoradiation therapy (CCRT) in order to quantify the effects of CCRT on tongue function and structure. CCRT for advanced oropharyngeal cancer commonly leads to tongue base dysfunction and dysphagia. However, no preclinical models currently exist to study the pathophysiology of CCRT-related morbidity, thereby inhibiting the development of targeted therapeutics. STUDY DESIGN/METHODS:Animal model. METHODS:Twenty-one male Sprague-Dawley rats were randomized into three groups: 2 week (2W), 5 month (5M), and control (C). The 2W and 5M animals received cisplatin, 5-fluorouracil, and five fractions of 7 Gy to the tongue base; the C animals received no intervention. In vivo tongue strength and displacement, as well as hyoglossus muscle collagen content, were assessed. Analyses were conducted 2 weeks or 5 months following completion of CCRT in the 2W and 5M groups, respectively. RESULTS:Peak tetanic and twitch tongue forces were significantly reduced in both 2W and 5M animals compared to controls (tetanic: P = .0041, P = .0089, respectively; twitch: P = .0201, P = .0020, respectively). Twitch half-decay time was prolonged in 2W animals compared to controls (P = .0247). Tongue displacement was significantly reduced across all testing parameters in 5M animals compared to both the C and 2W groups. No differences in collagen content were observed between experimental groups. CONCLUSIONS:The current study is the first to describe a preclinical model of CCRT to the head and neck with an emphasis on clinical relevance. Tongue strength decreased at 2 weeks and 5 months post-CCRT. Tongue displacement increased only at 5 months post-CCRT. Fibrosis was not detected, implicating alternative causative factors for these findings. LEVEL OF EVIDENCE/METHODS:NA Laryngoscope, 2017.
PMID: 29280493
ISSN: 1531-4995
CID: 2895892
HPViewer: sensitive and specific genotyping of human papillomavirus in metagenomic DNA
Hao, Yuhan; Yang, Liying; Galvao Neto, Antonio; Amin, Milan R; Kelly, Dervla; Brown, Stuart M; Branski, Ryan C; Pei, Zhiheng
Motivation/UNASSIGNED:Shotgun DNA sequencing provides sensitive detection of all 182 HPV types in tissue and body fluid. However, existing computational methods either produce false positives misidentifying HPV types due to shared sequences among HPV, human, and prokaryotes, or produce false negative since they identify HPV by assembled contigs requiring large abundant of HPV reads. Results/UNASSIGNED:We designed HPViewer with two custom HPV reference databases masking simple repeats and homology sequences respectively and one homology distance matrix to hybridize these two databases. It directly identified HPV from short DNA reads rather than assembled contigs. Using 100,100 simulated samples, we revealed that HPViewer was robust for samples containing either high or low number of HPV reads. Using 12 shotgun sequencing samples from respiratory papillomatosis, HPViewer was equal to VirusTAP, and Vipie and better than HPVDetector with the respect to specificity and was the most sensitive method in the detection of HPV types 6 and 11. We demonstrated that contigs-based approaches had disadvantages of detection of HPV. In 1,573 sets of metagenomic data from 18 human body sites, HPViewer identified 104 types of HPV in a body-site associated pattern and 89 types of HPV co-occurring in one sample with other types of HPV. We demonstrated HPViewer was sensitive and specific for HPV detection in metagenomic data. Availability/UNASSIGNED:HPViewer can be accessed at https://github.com/yuhanH/HPViewer/. Contact/UNASSIGNED:Zhiheng.pei@nyumc.org. Supplementary information/UNASSIGNED:Supplementary data are available at Bioinformatics online.
PMID: 29377990
ISSN: 1367-4811
CID: 2933702
Nanoparticle delivery of RNA-based therapeutics to alter the vocal fold tissue response to injury
Hiwatashi, Nao; Kraja, Iv; Benedict, Peter A; Dion, Gregory R; Bing, Renjie; Rousseau, Bernard; Amin, Milan R; Nalband, Danielle M; Kirshenbaum, Kent; Branski, Ryan C
OBJECTIVES/HYPOTHESIS/OBJECTIVE:Our laboratory and others hypothesized that Smad3 is a principle mediator of the fibrotic phenotype in the vocal folds (VFs), and we further posited that alteration of Smad3 expression through short interfering (si)RNA holds therapeutic promise, yet delivery remains challenging. To address this issue, we employed a novel synthetic oligomer, lipitoid, complexed with siRNA to improve stability and cellular uptake with the goal of increased efficiency of RNA-based therapeutics. STUDY DESIGN/METHODS:In vitro study and in vivo animal model. METHODS:In vitro, lipitoid cytotoxicity was quantified via colorimetric and LIVE/DEAD assays in immortalized human VF fibroblasts and primary rabbit VF fibroblasts. In addition, optimal incubation interval and solution for binding siRNA to lipitoid for intracellular delivery were determined. In vivo, a rabbit model of VF injury was employed to evaluate Smad3 knockdown following locally injected lipitoid-complexed siRNA. RESULTS:In vitro, lipitoid did not confer additional toxicity compared to commercially available reagents. In addition, 20-minute incubation in 1× phosphate-buffered saline resulted in maximal Smad3 knockdown. In vivo, Smad3 expression increased following VF injury. This response was significantly reduced in injured VFs at 4 and 24 hours following injection (P = .035 and .034, respectively). CONCLUSIONS:The current study is the first to demonstrate targeted gene manipulation in the VFs as well as the potential utility of lipitoid for localized delivery of genetic material in vivo. Ideally, these data will serve as a platform for future investigation regarding the functional implications of therapeutic gene manipulation in the VFs. LEVEL OF EVIDENCE/METHODS:NA Laryngoscope, 2017.
PMCID:5910268
PMID: 29238989
ISSN: 1531-4995
CID: 2844092
Impact of medialization laryngoplasty on dynamic nanomechanical vocal fold structure properties
Dion, Gregory R; Benedict, Peter A; Coelho, Paulo G; Amin, Milan R; Branski, Ryan C
OBJECTIVES/HYPOTHESIS: Although the primary goal of medialization laryngoplasty is to improve glottic closure, implant placement is also likely to alter the biomechanical properties of the vocal fold (VF). We sought to employ novel, nanoscale technology to quantify these properties following medialization based on the hypothesis that different medialization materials will likely yield differential biomechanical effects. STUDY DESIGN: Ex vivo. METHODS: Nine pig larynges were divided into three groups: control, Silastic (Dow Corning, Midland, Michigan, U.S.A.) block medialization, or Gore-Tex (W.L. Gore & Associates, Newark, Delaware) medialization. Laryngoplasty was performed on excised, intact larynges. The larynges were then bisected in the sagittal plane and each subjected to dynamic nanomechanical analysis (nano-DMA) at nine locations using a 250-mum flat-tip punch and frequency sweep-load profile across the free edge of the VF and inferiorly along the conus elasticus. RESULTS: Silastic block and Gore-Tex implant introduced increased storage and loss moduli. Overall, storage moduli mean (maximum) increased from 38 kilopascals (kPa) (119) to 72 kPa (422) and 129 kPa (978) in control, Gore-Tex, and Silastic implants, respectively. Similarly, loss moduli increased from 13 kPa (43) to 22 kPa (201) and 31 kPa (165), respectively. Moduli values varied widely by location in the Silastic block and Gore-Tex groups. At the free VF edge, mean (maximum) storage moduli were lowest in the Gore-Tex group, 20 kPa (44); compared to control, 34.5 kPa (86); and Silastic, 157.9 kPa (978), with similar loss and complex moduli trends. CONCLUSION: Medialization laryngoplasty altered VF structure biomechanical properties; Silastic and Gore-Tex implants differentially impact these properties. LEVEL OF EVIDENCE: NA. Laryngoscope, 2017.
PMCID:5891392
PMID: 28990693
ISSN: 1531-4995
CID: 2732042
Impact of vocal fold augmentation and laryngoplasty on dyspnea in patients with glottal incompetence
Dion, Gregory R; Fritz, Mark A; Teng, Stephanie E; Marcus, Sonya; Fang, Yixin; Branski, Ryan C; Amin, Milan R
OBJECTIVES/HYPOTHESIS: Given that the vocal folds are active organs of respiration, reports of dyspnea in the context of glottic insufficiency are not uncommon. We hypothesize that improved glottal closure via framework surgery or vocal fold augmentation improves dyspnea symptoms. STUDY DESIGN: Retrospective review. METHODS: Charts of patients undergoing procedures to correct glottal insufficiency, either via vocal fold augmentation (VFA) or medialization laryngoplasty (ML) between December 2012 and September 2015 were reviewed (n = 189). Modified Borg Dyspnea Scale (MBDS) and Modified Medical Research Council Dyspnea Scale (MMRCDS) data were collected before and after intervention. Age, body mass index (BMI), and sex, as well as pulmonary and cardiac comorbidities were considered. Subgroup analysis was performed on individuals with subjective dyspnea prior to intervention. RESULTS: For the entire cohort, differences in the MMRCDS and MBDS were not statistically different pre- and postintervention (P = .20 and P = .12, respectively). Patients with BMI <30 experienced more improvement on the MBDS (P = .03). Both the MMRCDS and MMBDS improved post-procedure (P = .001 and P = .001, respectively) in patients reporting dyspnea prior to intervention. CONCLUSIONS: Patients with glottic insufficiency and dyspnea prior to intervention to improve glottic closure had a significant reduction in dyspnea following treatment. Conversely, subjects without complaints of dyspnea prior to intervention had variable outcomes with regard to dyspnea symptoms. Additionally, based on data from the entire cohort, VFA or ML did not worsen dyspnea symptoms. These data may assist in counseling and/or selection of patients considered for procedures to improve glottic closure. LEVEL OF EVIDENCE: 4 Laryngoscope, 2017.
PMID: 28940470
ISSN: 1531-4995
CID: 2708462