STEVE DOAK, M.D... .. continued...

So you are scheduled for a followup MBS with special maneuvers.  Let me bring you up to date on my thinking.   You raised the question of why the surgeon who did your neck lift did not make sure you could extend your neck before closing the incision.  He may well have.  A tube would have been in your trachea, having been passed through your mouth or less likely through your nose and this would have kept your airway open and the resistance you feel to extension while awake might have been overcome by his manipulations under anesthesia. From my viewpoint, the organic cause of your trouble swallowing was established by the MBS and your airway problems seem explained by the airway narrowing on the C-Spine film you have on your web site.  BTW, that film needs a date on it, unless I am missing something.  Was it taken during your recent ER visit? Now for the next MBS.  I think the main thing that needs to be established is that the airway problems & swallowing problems change with changes in position of the mandible, as you suggested previously with regards to the first MBS and the cephalometric radiographs.  This of course would help establish a rationale for surgery or perhaps Botox.  Airway problems are supposed to catch the attention of real doctors, if something organic is established and I think you want maximum documentation. I am a pretty hands-on guy once somebody gets me interested enough in a problem to get me off my duff and my approach would be very straightforward and problem-oriented, basically directed toward the back of the tongue and the way it protrudes into the airway. Your MBS was apparently performed with fluoroscopy & video & I suspect that no plain films were taken. My approach would be to get a series of fluoroscopically motivated spot films.  These could be done using regular spot films but would best be done with a so-called roll-film or cut-film camera, available on one or more machines in a good X-Ray department, producing beautiful little 4 inch images taken off the image intensifier the same way the video was.  These are not “dynamic” but offer superior static detail and more easily shared with others including those on your web site. These cameras typically have fields of view (FOV) of 4, 6, & 9 inches at minimum.  These studies would not require contrast material and can be done by the radiologist working without a speech therapist.  Your doctor needs to talk to the MD fluoroscopist ahead of time so that he knows exactly what the goals of the examination are. 
 
 Now for moving the mandible around.  The main thing is to preferably keep your fingers out of the shadow of the airway.  How about just elevating the angles of the mandible with your index & middle fingers, which keeps your hands low, or with your thumbs, which also keeps your hands low if you make fists?  Remember, my goal would be to show changes in the airway at the base of the tongue. I would anticipate that the airway could be seen through your fingers especially with tight collimation. Just remember that we need the general picture and we can put up with a few artifacts (fingers). Anything else would be at the discretion of the speech therapist and the radiologist. You might be surprised at how fast a radiologist can produce spot films, especially with one of the cameras.  I saw your account of how you wound up in the ER You should type up a summary of your case to have with you if this happens again. I saw a picture of some man on your website and I assumed he is your husband or fiancée.  I would hope that he is supportive and perhaps assertive if something similar happens again & he should he should have his own copy of your summary so that you don’t get shunted out of his sight. Many of the cases of shortness of breath in the ER are due to anxiety reactions and so-called hyperventilation and you don’t want to be lumped into that crowd.   You mention that your breathing problems are getting worse.  This is conjecture, but perhaps the tongue is being overcome by constant traction or perhaps you get tired of fighting it, which is understandable.  So be sure to discover what manual traction on your tongue does for your breathing.  I know very little about airway problems in the clinical setting so you might ask your doctors about the plastic airways that slide over the tongue and are used to keep the tongue forward in some situations.  As I see it, a CT or MRI might or might not help furnish a roadmap for therapy.  I am surprised nothing showed up on your first MRI but nothing was called on the C-Spine on your website either.   
 
 Robert J Stanley MD is now editor of AJR and he was previously chairman down at UAB and he and his colleagues used to review cases sent in by other radiologists and they were very good at it, doing it for free and they seemed to enjoy doing it.  The chairman there now is his long-term colleague and one of your doctors might inquire if he knows somebody who would be willing to review some of your studies for you. http://www.rad.uab.edu:591/people/FMPro?-DB=UAB_Rad_people.FMP&-Lay=Layout1&-error=search_error.htm&-Format=search_results.htm&-Op=gt&sort=0&-skip=0&-max=All&-SortField=sort&-SortORder=Ascending&-find I always make it a point to gain control of my films as soon as others have finished evaluating them. Old films are not kept very long anyway.  You will be made to promise to return them and then you might get a reminder note to return them, but I just keep them anyway and nobody seems to care.  Besides in some hospitals, they circle the wagons if they sense trouble and things start to disappear,  Somebody needs to be proactive in a problematic case such as yours, since lots of studies such as CT & MRI are read in isolation with no plain films around for comparison.  Especially in big hospitals. One more thought, my approach to problems revolves around what you do and how you do it rather than what you call it.

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 I have had  conversations  with Lucille  and I find her to be a delightful person with no evidence of hypochondriasis or hysteria.

Having had lots of experience with surgeons in three years as a surgery intern and resident and as a practicing radiologist and I will attest to Lucille's assertion that many doctors, particularly surgeons and especially plastic surgeons have an automatic reflex to begin blaming the patient upon the occurrence of any bad result.  This may represent either a response learned during training or an underlying narcissistic tendency, so commonly found in lawyers.  

It is amazing to me that even though plastic surgeons are all board-eligible or board-certified general surgeons before beginning plastic surgery training, that in this particular case they seem to have forgotten the first tenet in treating trauma, whether it be the trauma of plastic surgery or otherwise, which is that one must guarantee the adequacy of the airway.  Just because they are exalted plastic surgeons at MGH does not mean they should stop being doctors.

Lucille relates to me that the plastic surgery journals are full of articles each month relating to new and untested surgical procedures, almost the new operation of the month sort of thing.  She describes the plastic surgical residents at MGH as using the clinic patients, under the tutelage of the attendings, perhaps so they can generate even more articles about innovative procedures, as guinea pigs.  “Using patients as experimental animals” is the expression that is used in my circles and I could give you plenty of examples in a one on one but this is not the time or place.

I view the explanation of Lucille's problems as quite simple. She had a neck lift and the surgeon obviously tied his repair directly or indirectly into the tissues related to the base of the tongue and the first person to recognize this was the speech pathologist who did her first MBS and described the base of the tongue as appearing obviously anchored or fixated.  This is what Lucille had figured out for herself a long time before but she had no way to prove it until I suggested she try pulling out on her tongue using a cloth for traction and this led to immediate and dramatic relief of her trouble breathing, as it pulled the base of her tongue out of her oropharynx. This, to me, would constitute good evidence to get on with the program and try to find a competent, experienced problem-solving surgeon used to operating in this area to explore the operative site and presumably take down at least part of the previous surgical procedure. Her ENT however wants more dramatic and direct demonstration of the problem and I can agree with this, considering today’s medico-legal climate.

The problem as I see it is that so many people involved in her case have been caught up in overly-conventional thinking.  Her second MBS resulted in almost a repeat of her first one since she was not able to move her mandible around much with the forceps and her fingers got in the way of  the visualization of her airway and the single frames of her second MBS posted on her website did not reveal adequate collimation or composition to cut out the air space in front of the neck and concentrate on the oropharynx.  The whole thing was over so fast that that there was not time to get the study focused on the base of the tongue let alone do the tongue traction maneuvers.

Her ENT said he wanted an airway fluoroscopy and everybody sort of goes blank instead of asking what is it exactly they want to see and the answer would be to prove that tongue in the neutral non-swallowing position is way back in throat and that it pops forward with traction and this forward displacement is associated with marked improvement in breathing, as related to inspiration.

She had a pulmonary function test and the fact that the numbers were normal was used as evidence against her having a problem.  Lucille  relates to me now that the tube in her mouth with the bite block altered the position of her tongue and made breathing easier but I am not sure if she told them about it or if they would have listened to her if she had.  In any event this serves to prove the old adage that sampling the data or doing a test of any degree of invasiveness often alters the data. 

She relates to me that her oxygen sats are normal when she walks into the office so I responded that she should get them to walk her around until she gets short of breath and check them again. 

As one can tell I am trying to instill more of a problem solving mentality into her problems.

So at this point in time I think she has real problems which may be treatable by taking down the previous surgical repair or perhaps by botoxing her, if the problems are related to contraction of the platysma.  Botox has come up from time to time and now might be the time to go with it.  Again as a temporizing measure, she might try a plastic airway, to the extent that she can tolerate it.

As for justification for further intervention I would try to prove oxygen desaturation with exercise and try to get some good collimated pictures at fluoroscopy using spot films and cine, to show the tongue popping in and out of the oropharynx with traction and correlate that with symptoms.  Remember, we are supposed to act like doctors and not robots, right?

 I wish her good luck.