* Analysis by Radiologist, Steve Doak,M.D.
In my effort to obtain as many professional opinions as possible regarding my case, I posted a message on AuntMinnie.com, a radiology forum, and asked if they would take a look at my x-rays and Modified Barium Swallow studies.
I was extremely encouraged by the responses I received, especially from Dr. Steve Doak, a retired radiologist living in Boulder, CO. He reviewed my case with thoroughness and care. I am deeply grateful for the time and attention he has devoted to every detail of my case in helping me move towards a working solution to my problem.
The following assessments certainly reflect the most accurate understanding of my problem. Dr. Doak’s insight is quite remarkable, given that he never had the opportunity to examine me, as have the many surgeons I have consulted, but was able to understand the anatomical mechanics involved through critical analysis of the information provided. I am ever grateful for his kindness and willingness to help.
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STEVEN DOAK, M.D.
EVALUATION AND SUGGESTIONS:
Obviously, we are looking at a situation where there is probably distortion of the anatomy that may be difficult to image and then to understand once the images are obtained. I frankly see no reason why your fingers should interfere with a MBS, but then again I am more flexible and less dogmatic than some. After all the density of the barium far overshadows the density of your fingers and radiologists are supposed to be trained to tell the difference. And that study with your fingers pulling on the mandible would give a direct straightforward look. So, why not do the studies with your fingers after you have done the study their way, because if you use some metallic device etc, the question might arise in your mind or their minds that the study might not have been a fair representation of your fingers maneuver. I will admit that even as a radiologist and fellow-physician, I sometimes have trouble influencing my own medical care but I am persistent. The next shot would be a good multiplanar CT or MRI study, in a place where somebody understands them. Which is used would depend on what is available and what people are familiar with. The CT specification would call for a multidetector spiral CT with at least 4 detectors obtaining 1 mm slices, which would allow looking at the anatomy in way desired, in any plane. A good multiplanar study in the right hands has the potential to reveal anatomic detail that one can only guess about on plain film studies & fluoroscopy. One could do runs in various positions with various maneuvers etc. As always, often the first obstacle is getting somebody interested in your problem. Regarding distortion, we have a dictum in radiology, once the surgeons have been in, a lot of the bets are off, unless we know or can surmise exactly what went on. Regarding your operation report, there is no doubt that surgeons often tailor their op reports to cover their mistakes.
As preamble, doctors like other professionals, are to a large extent pattern readers, which means that they recognize most readily what they already understand & are familiar with and that conversely they are much more likely to miss something they have never seen or which makes them uncomfortable. I agree that there is narrowing of the airway where you have placed the arrows. The tongue seems humped up posteriorly (toward the rear) and pulled into the airway, producing narrowing. Obviously, my familiarity with your history & the results of the MBS made my observations pretty easy. In all fairness, radiologists are not often presented with such studies as your particular C-Spine & the tongue in this region is not often a point of interest. I can only pray that I am having a good day if I see the next study such as yours. I have included a link to a normal study, chosen by its publishers completely at random. You might like to post it beside your own image.http://www.rad.washington.edu/RadAnat/CSpineLateral.htmlI will try to send you others. You might go to RADQUIZ.COM, which has other images but this one is representative. You might find some that show more of the tongue. MSK stands for musculoskeletal, which is where pictures of the spine might be found. Searching around for plain films is difficult at times because so much of the stuff published is CT or MRI, which are already digital & ready to go. BTW, I thought your reproduction of the C-spine was quite good. You might check to see if you have others that might show the tongue even better, especially toward the front, to better understand the humping, no pun intended. A saggital view from the CT or MRI would be ideal for this detail. A saggital view is the one that suggests the lateral view from the C-spine, like cutting a banana into two equal pieces the long way. Axial means slicing it into round pieces, so you can understand some of the terms.
As you probably don’t know, dental restoration material such as amalgam & crowns can interfere with CT but not MRI, although the latest scanners with the thin 1 mm slices are considerably less affected. The standard arguments apply. CT is more readily available, quicker, easier, more likely to give a good study unless metal (amalgam) interferes, and gives better anatomic detail, whereas MRI give better delineation of soft-tissue densities, such as the muscles and may be better at delineating scar tissue especially if Gadolinium is used. There is lots of stuff out there concerning the anatomical area that interests you, but it primarily deals with tumors (malignancies) & infections including abscesses.There was a recent post on your thread that went into detail about the platysma & skin being stretchable etc. But consider the anatomy of the tongue. The tongue is a powerful muscle with a lot of mobility. It is attached posteriorly-inferiorly to the floor of the mouth in the midline but the rest is not attached and the anterior 2/3 is referred to as the free part. So if something exerts traction on the posterior part of the tongue, the anterior free part has no attachment and no way to exert counter-traction and it seems to me the tongue could be easily pulled back into the airway. There is apparently only one person who knows what went on in your surgery and he is not talking, so we are left with conjecture. I would guess that perhaps the platysma or whatever he was trying to tie in superiorly might have gotten tied into the base of the tongue or something leading to the tongue, but one must realize that my analysis is based strictly on general knowledge since I have absolutely no knowledge of plastic surgery itself. The platysma is just a sheet-like muscle that has attachments only to the skin so it has to balance out tensions onto other parts of itself & onto the skin, so in your case we might be postulating a part of the platysma that is exerting unbalanced traction on the tongue, something the tongue has no way to resist. That is just my conjecture and I would certainly not qualify as an expert in that area. So to test this theory, have you tried pulling on your tongue using a dry piece of cloth such as a washrag for better traction and did it help? There are lots of botox operators out there and I would be interested if your symptoms got better after botox and if manual traction on the tongue was then more effective.
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.
Stumble It!
