CC ENT SPECIALISTS
4-21-O4 LUCILLE IACOVELLI DOB 10/18/49
CC: Returns for re-evaluation of her dysphagia and SOB. HPI: 54-year-old, white female who since last seen 9-11-03, has been communicating with me via fax and phone messages. She asked me to order repeat modified Ba esophagram which we did on 12-9-03. Maria DePesquale interpreted the study. Patient was noted to present with pharyngeal dysphagia essentially unchanged from her previous evaluation which was characterized with reduced laryngeal elevation. She also noted the patient continued to complain of difficulty breathing. Diet as tolerated, was recommended with the continued use of a chin tuck. She also had a lateral soft tissue projection of the neck done and brings that with her today. She pointed out to me that the tongue base appears retrodisplaced; in my view, it does appear the base of tongue is closer to the posterior oropharynx than the average patient.
The patient states at present she must flex her neck forward in order to swallow comfortably. She also feels better about her breathing with the head flexed forward and down to toward the right clavicle. She pointed out to me that when she puts her head in the neutral position, the corners of her mouth go down and she also has tightening of her platysma. especially on the right. She states she continuously feels like the airway will block off and it is difficult to drive because of this.
PHYSICAL EXAMINATION: GENERAL: Well developed, well-nourished, white femalewho is emotionally upset, but in no apparent distress. She tends to keep the neck flexed forward and to the right. EARS: Auricles arc clear, no lesion. 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: Corners of mouth are depressed; the position of the tongue tends to be low and posterior. Oral cavity mucosa is normal. OROPHARYNX: No mucosal lesions. Soft palate and posterior oropharynx appear clear. Tonsillar fossae are unremarkable. NECK: No palpable adenopathy, masses, thyromegaly or thyroid nodularity. Salivary glands are normal to palpation. CERVICOFACIAL SKIN: Normal appearing. Well-healed, preauricular face-lift incisions. Again, when the patient puts her chin into the neutral position, the comers of the mouth become markedly depressed. She also tends to have tensing of the platysma muscles on the right, so prominent I can see several areas of "bow-stringing". PROCEDURE: FIBEROPTTC LARYNGOSCOPY, with a 3.7 mm Olympus scope after. the application of 2% Xytocaine, 0.5% Phenylephrine and 2% Pontocaine. The tongue base does appear to be displaced posteriorly. The epiglottis is retroflexed, the tip is about 1 cm away from the posterior oropharynx. The valleculae are normal. The endolarynx, pyriform sinuses and postcricoid mucosa are normal. There is no pooling of secretions. The true vocal cords have normal morphology and mobility. Immediate subglottis is clear.
IMPRESSION: 1. Continued complaints of dysphagia and a feeling of airway constriction, which the patient attributes to a sequela of revision facelift surgery, several years ago. Unlike previous fiberoptic exams, the tongue base does appear to be somewhat retrodisplaced today with retroflexion of the epiglottis. RECOMMENDATIONS: Discussed today's findings with the patient. She was made away that I, unfortunately, have nothing to offer her pharmacologically or surgically. She was aware of that prior to coming in today. She mainly came here for documentation purposes. I wished her well. F/u with me at this point will be p.r.n.
SFM/br C: Emerald Physicians. R: 4/25 T: 5/6
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This report confirms my original impression of my x-ray taken in the ER in October 2003 as showing a narrowed airway caused by the base of the tongue pulling down. It confirms the opinion of radiologist Steve Doak, M.D. as to the cause being the tongue base. This is an example of how diagnostics can be misinterpreted. Your doctor will take the report at face value and never see the film. The doc assumes it is accurate. If I had not obtained the original x-ray myself and questioned the reading, I would not have gotten this far. Even more dangerous is the fact that both of these reports remain read as "normal" in the hospital records. To muddy the waters even more, the ER doc wrote into my record "patient is dulusional and psychotic about her breathing and swallowing", in spite of having reports of two MBS studies with diagnosis of dysphagia at his finger tips. This is how layer upon layer of MEDICAL ERRORS perpetuate and ultimately turn into full blown disasters for the patient.
Note: 11/22/07 - Film on right taken in 4/04 shows worse narrowing of airway than the film Dr. Mucci reviewed. Yet this also was read as "normal" and is recorded that way in my records at CCH. I have the original films, which I was advised by Dr. Steve Doak NOT to return to CCH, but to keep myself. Evidently, the fact that I was only able to maintain the posture in which the film was taken for less than one minute, because I CANNOT breathe with my head up seems to be an insignificant factor in reading these for evidence of airway obstruction, despite the fact that I explained this to the ER doctor. I swore after this ER experience in 4-2004 that I would rather let nature take its course regarding ANY emergency medical situation rather than subject myself to the possible dangers involved with doctors making assessments based on previous false information.
