7-2-04  
LUCILLE IACOVELLI 
DOB 10/18/49

CC: Returns for repeat fiberoptic evaluation of her upper airway, at her request. BPI: 54-year-old, white female who since last seen here, 4-21-04, has been evaluated by Dr. Timothy Herrick, pulmonologist, PFTS were performed which suggested a fixed upper airway obstruction with flattening of both the inspiratory and expiratory limbs. The patient has been discharged from his care, as there is nothing he has at his disposal to treat the problem from a pulmonology perspective.
 
The patient states today that she continues to have a sensation of airway obstruction when the head is in certain positions, i.e. upright. She has developed compensatory strategy by keeping her head tilted forward and to the right, whereby, she states the sensation of obstruction is improved. She is forced to drive with the head in that position. She continues to complain of debilitating preauricular pain. ROS: Negative for stridor, positive for SOB with head in the upright position.

PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished, white female with neck flexed forward and to the right. The corners of her mouth are markedly depressed, but she is in no apparent distress. EARS: Auricles are clear, no lesions. External auditory canals are clear. Tympanic membranes are intact and fully mobile by pneumatic otoscopy. NOSE: Dorsum is normal. Anterior rhinoscopy: Septum is midline. Inferior turbinates are normal in appearance. Posteriorly, no purulence or polyps. MOUTH: Clear, no lesions. Normal lips and residual dentition. No ankyloglossia. OROPHARYNX: No mucosal lesions. Soft palate and posterior oropharynx appear clear. NECK: No palpable adenopathy, masses, thyromegaly or thyroid nodularity. Salivary glands are normal to palpation.

PROCEDURE: . FIBEROPTIC UPPERAIRWAY EXAM (LARYNGOSCOPY), with a 3.7 mm Olympus scope through the left nasal cavity. After the application of 2% Xylocaine, 0.5% Phenylephrine and 2% Pontocaine. I had the patient put her head in the upright position today, in contradistinction to the last exam, there was somewhat less glossoptosis of the tongue base and retroflexion of the epiglottis. The patient could voluntarily reposition the tongue base posteriorly and the epiglottis assumed a position about 1 cm from the posterior hypopharageal wall. The endolarynx, pyriform sinuses, postcricoid mucosa and true vocal cords were normal.  With the patient's neck flexed anteriorly and to the right, the airway was wide open.

IMPRESSION: . Continued complaints of dysphagia and positional airway obstruction, which patient attributes to adverse sequelae after revision rhytidectomy. RECOMMENDATIONS: . Discussion with the patient. Reiterated I have nothing to offer, surgically from a general otolaryngology perspective. She will call Dr. Der Sarkissian to see if he is willing to offer any type of corrective surgical procedure. I will continue to offer her moral support here on the Cape and if there is any significant change in her airway status, requiring reassessment, I will be available for that as well. Flu otherwise will be p.r.n.

Steven F, Mucci, MD

SFM/br
CC: Dr. Der-Sarkissian, Emerald Physicians and Dr. T. Herrick R: 7/6 T: 7/9