Cape Cod Hospital, Hyannis, MA 02701
Ord Phys: Steven Mucci, M.D.
Att Phys: Steven Mucci, M.D.
MODIFIED BARIUM SWALLOW
DATE OF EVALUATION: 12/09/03
MEDICAL HISTORY: THE PATIENT IS A 54 YEAR OLD FEMALE WHO RETURNS AS AN OUTPATIENT FOR HER SECOND MBS, THE INITIAL COMPLETED BY THIS CLINICIAN ON 5/02/03. SHE UNDERWENT COSMETIC FACE AND NECK LIFT SURGERY 2.5 YEARS AGO IN INDIANA AND HAS COMPLAINED OF BREATHING AND SWALLOWING DIFFICULTIES SINCE THAT TIME. PRIOR MBS RESULTS SHOWED DYSPHAGIA WITH SOME PREMATURE SPILL INTO THE PHARYNX AND TRANSIENT LARYGNEAL PENETRATION WITH THIN LIQUIDS WHICH WAS ELIMINATED WITH A CHIN TUCK MANEUVER WHICH THE PATIENT WAS SPONTANEUSLY DOING. TODAY, THE PATIENT COMES EQUIPPED WITH 2 PAIRS OF FOCEPS TO ASSIST HER IN A MANEUVER WHERE SHE PULLS UP ON THE PLATYSMAS MUSCLES WHICH SHE SAYS IMPROVES NOT ONLY HER SWALLOW FUNCTION, BUT HER BREATHING, AS WELL. SHE REPORTS SENSATION OF REDUCED AIRWAY AND HAS RECENTLY HAD AN E.R. VISIT 10/21/03 FOR SAME. SHE IS C/O DIFFICULTY BREATHING THAT REQUIRES HER TO KEEP HER NECK FLEXED AND IS C/O ASSOCIATED NECK PAIN NOW, AS WELL. THIS IS AFFECTING HER DAILY ACTIVITIES AND ESPECIALLY DRIVING. OTHER PMHX INCLUDES MITRAL VALVE PROLAPSE AND NARCOLEPSY. SOCIAL HX: SHE IS A GARDENER. SHE IS VEGETARIAN.
CONSISTENCIES ADMINISTERED
THIN LIQUIDS, LORNA DOONE COOKIE.
ORAL PREPARATORY PHASE
This patient showed: Normal control and bolus transit: Efficient oral motility and bolus formation; no oral residue; mastication is brisk and thorough.
REFLEX INITIATION PHASE
This patient showed: ANATOMY: Normal: reflex initiated at the back or base of tongue above the epiglottis. TIMING: Normal: no hesitation; smooth and continuous motility from posterior tongue into pharynx.
PHARYNGEAL PHASE (Pharyngeal - Laryngeal, Cricopharyngeal)
This patient showed: Limited laryngeal excursion; epiglottis may achieve horizontal position, but fails to invert fully; a laryngeal vestibule gap may be seen during the swallow.
PHARYNGEAL CLEARANCE (PERISTALSIS)
This patient showed: Mild residue: «10%) of a small bolus remains in the mid and/or lower pharynx after the first swallow.
ASPIRATION
This patient showed: no aspiration. There is transient laryngeal penetration on thin liquids with head in neutral position. This is eliminated when the patient uses a chin tuck. This is reduced somewhat, but not eliminated when the patient pulls up on the platysma muscles.
PHARYNGEAL - ESOPHAGEAL SEGMENT
(Proximal or cervical esophagus; upper esophageal sphincter/UES) This patient showed: Normal Relaxation of the UES; caliber of opening is full.
TYPE OF MODIFICATION
POSITION OF HEAD:
Chin Down Tuck-------------Helpful
"LIFTING" NECK MUSCLES-----Somewhat helpful
SUMMARY AND IMPRESSION:
The patient continues to present with pharyngeal dysphasia, essentially unchanged from prior evaluation, which is characterized by reduced laryngeal elevation and intermittent reduction in epiglottic deflection with resulting transient laryngeal penetration of thin liquids worse with head in neutral position. Penetration is eliminated with a chin tuck and reduced with the patient lifting up the muscles of her neck with forceps. Difficulty breathing is also major complaint which she describes as a sense that her tongue is somehow obstructing her airway.
Signed Electronically 12/17/03
MARIA DEPASQUALE, MS CCC-SLP
SPEECH-LANGUAGE PATHOLOGIST
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Left: Method. Pull with forceps Right: Video fluoroscopy
* My note: The fact of visible improvement in swallowing with upward pull on platysma (in opposite vector of INAPPROPRIATE tension which was employed in my surgery) is ABSOLUTE PROOF that failure to release this muscle with a transverse incision is the cause of my swallowing disorder. Of course, I am not able to FULLY correct this by manual manipulation of the tissue with fingers or forceps because it is IMPOSSIBLE for me to place that much opposing force to FIXED and AGGRESSIVELY EXCISED tissue. It takes all the strength in my fingers simply to grasp and relieve this tension for a few seconds, as THE TISSUE ITSELF IS SO SCANT AND UNDER SO MUCH TENSION THAT IT PULLS RIGHT THROUGH MY GRASP.
Grasping sufficient tissue between forceps for the MBS did not allow a strong enough hold, as this would have cut right through my flesh. This is not a difficult problem for any surgeon to understand. It is so blatantly EXTREME that only a surgeon who is deliberately trying to minimize such a catastrophe would fail to recognize its seriousness and functional repercussions.. It is very odd, indeed, that my ENT as well as the speech pathologist who performed and read the study, consider this to be "tangible" evidence of a specific muscle (platysma) is exerting tension sufficient enough to alter the internal structures of the neck (tongue base and epiglottis) to cause dysphagia. The force (tangible and measurable) demonstrates an improvement (tangible difference in the position of internal structures when force is applied). Yet this study was IGNORED by the very surgeons who have the most experience with this anatomy. How do they explain this?

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