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Vincenzo Altrudo was struggling. At age 5, he had difficulty hearing, eating, and sleeping, and a long bout of strep throat. He lost 5 pounds at a time when he should have been gaining weight. He didn’t complain much, but his mother had that gut feeling that her son needed help.
And though she initially scheduled an appointment with an ear, nose, and throat (ENT) doctor who treats adults and children, that unique radar that mothers have told her to bring her son to a pediatric ENT specialist at UPMC Children’s Hospital of Pittsburgh.
That decision changed their lives.
“Having a pediatric ENT specialist made sense to me because they know kids. An ENT doctor that was an adult doctor might not have caught Vincenzo’s other issues,” says Vincenzo’s mother, Lori Altrudo.
From Vincenzo’s first visit on April 3, 2019, pediatric otolaryngologist Reema Kirit Padia, MD, suspected that he would need a tonsillectomy, adenoidectomy, and bilateral myringotomy and tubes. They are among the most common pediatric surgical procedures, often done for children with frequent throat and ear infections.
According to the 2017 National Health Statistics Reports, 289,000 ambulatory tonsillectomies are performed annually in the United States for children younger than 15 years of age. UPMC Children’s did more than 1,900 in 2019.
Bringing a child to UPMC Children’s for the treatment of even the most common conditions can have significant benefits. UPMC Children’s is ranked among the top pediatric hospitals in the country in the most recent U.S. News & World Report Honor Roll of America’s Best Children’s Hospitals, and offers doctors and staff who are experienced with handling the special needs of pediatric patients.
In addition, patients at UPMC Children’s have enhanced access to subspecialty care throughout the hospital’s network of physicians. “The health care providers at UPMC Children’s are focused on the needs of kids,” says David Chi, MD, chief, Division of Pediatric Otolaryngology. “Whether it’s for the simplest or most complex treatment, we are used to taking care of children. We also have access to other specialists, so if additional referrals are necessary they can be made promptly.”
From drawing blood to alleviating fear before surgery, the team at UPMC Children’s is familiar with how kids think, feel, and react in stressful situations. “For ear care, a great asset that we have at UPMC Children’s is trained pediatric audiologists who know how to obtain tests from kids who are infants all the way up to teenagers who have developmental delays. An audiologist who doesn’t work with children often may not be able to get the same results as a pediatric audiologist,” says Dr. Padia.
An audiogram was one of the first tests Dr. Padia ordered for Vincenzo. At that initial clinic visit, she listened to Mrs. Altrudo’s three main concerns and examined Vincenzo. “The family felt like they had to turn up the volume more around him, though he had passed his school hearing test. Another concern was restless sleep at night with frequent wake-ups and mouth breathing. He also was having difficulty with feeding, gaining weight, and eating meats and solids,” says Dr. Padia.
An exam showed that Vincenzo had fluid behind both eardrums, a common cause of hearing loss in children. The audiogram was performed at the hospital the same day, and Dr. Padia reviewed the results with the family before they left. It confirmed he had hearing loss.
He also had enlarged tonsils and adenoids, which can make swallowing difficult and contribute to sleep apnea. The tonsils were a grade 4 on a scale of 1 to 4, with 4 being the worst. His adenoids were blocking 75% of his air passage at the back of his nose.
“Because the upper respiratory system is connected so intimately, we tend to see multiple concerns and multiple problems during one patient visit that we have to address,” she says.
Clinical guidelines suggest a tonsillectomy is appropriate for children who have seven episodes of tonsillitis in one year, or five episodes per year for two consecutive years, or three episodes per year for three consecutive years. Vincenzo had a history of ear and throat infections, and the family had been seeking help for swallowing issues since he was an infant.
Eating and swallowing issues and failure to gain weight also can be caused by gastrointestinal problems, so Dr. Padia used her UPMC Children’s connections to fast-track Vincenzo’s case to pediatric gastroenterologist Wednesday Sevilla, MD, MPH, CNSC. She evaluated him on April 9, within six days of Vincenzo’s initial encounter at UPMC Children’s.
“There was a lot of doctor-to-doctor communication that helped facilitate it,” says Dr. Sevilla. “We don’t work in isolation. We like to collaborate. That improves access for our patients.”
Vincenzo’s symptoms manifested as what appeared to his family to be a lack of appetite and a picky eater, but in addition to enlarged tonsils, he also had allergic inflammation of the esophagus. “As pediatricians, because we know how eosinophilic esophagitis presents in younger children, we were able to diagnose it right away,” says Dr. Sevilla.
The family faced multiple ENT procedures — tonsil and adenoid removal, and the insertion of ear tubes to drain fluid from behind the eardrums — as well as an upper endoscopy that was needed to confirm the eosinophilic esophagitis. Coordination of care meant Vincenzo could have all the procedures during the same surgical visit, and reduce his exposure to anesthesia, trips to the hospital, and emotional stress for the patient and family.
Vincenzo underwent surgery on July 16. “I work with kids. I know kids get anxious and scared. It was traumatizing for me because he was panicked,” says Mrs. Altrudo, a behavioral health liaison for local schools under the University of Pittsburgh Maximizing Adolescent Potentials program (and a former employee of the UPMC Community Care Behavioral Health Organization). “All of the staff at UPMC Children’s were amazing. They specialize in kids. I really do feel like they go above and beyond.”
The ENT portion of the surgery lasted about 45 minutes. A gastrointestinal specialist completed the endoscopy in about 20 minutes. Tonsillectomy, adenoidectomy, and bilateral myringotomy and tubes are often performed together, and many children are able to go home the same day. “We kept Vincenzo overnight because in his particular case we knew he already had trouble swallowing, and I wanted to make certain he was taking his pain medication appropriately and staying hydrated,” Dr. Padia says.
“I got teary-eyed the day we saw Dr. Padia for our follow-up. I said, ‘I don’t know how to thank you because you truly listened to everything,’” Mrs. Altrudo recalls. “We still might be fighting him to eat every day if it wasn’t for her and Dr. Sevilla. Mealtime was extremely stressful for me.”
Despite Vincenzo’s lifelong difficulties with eating and speech, no one had ever suggested he see a gastroenterologist, until they met with Dr. Padia, she adds. “I am so thankful for those two ladies, because they have given us answers.”
Medication is already helping to reduce Vincenzo’s eosinophilic esophagitis. Dr. Sevilla will continue endoscopic check-ups every eight to 12 weeks to determine if the esophagus is healed and the medication can be discontinued.
Dr. Padia will also monitor Vincenzo’s condition. “We will see him every year until we know that the tubes have come out on their own and the eardrum has healed appropriately. The tubes that we put in on average last about 12 to 18 months,” she says. “The hope is that once these tubes are out his Eustachian tubes will continue to mature and he won’t need a second set.”
Now 6, Vincenzo’s life in Plum with his parents Lori and Vincent, twin sister Sophia, and 8-year-old sister Angelina, is improving. He is hearing, eating, and sleeping better, although some minor speech issues remain. He went from having little energy to being an energetic soccer player. “He’s definitely better all the way around,” says Mrs. Altrudo.
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