~ Losing Face ~

* Report from Pulmonologist - May 2004

May 12, 2004

RE: Lucille Iacovelli

Reason for Consultation: Dyspnea

Dear Dr. Gour:

Thank you for asking me to see Lucille Iacovelli in pulmonary consultation. She is a 54 year old woman who presents for evaluation of dyspnea. Approximately seven years ago, this patient had a facelift performed at Massachusetts General Hospital. Approximately three years ago, she had a follow-up procedure, which involved a platysmaplasty for laxity of the submental tissues. Following that procedure, the patient developed significant tightness of the soft tissues in the submental region along the right side of the neck. With extension of her neck in the midline, the patient develops shortness of breath. In order to maintain airway patency, the patient keeps her head flexed and turned to the right. With her neck extended and her head in the midline position, the patient can maintain airway patency by applying pressure to the base of the tongue. Recent fiber-optic laryngoscopy by Dr. Mucci documented retro flexion of the epiglottis and a posteriorly displaced base of tongue. Previous PFTs have been within. normal limits.(* Note:  See below) .  A recent barium swallow demonstrated pharyngeal dysphasia with transient laryngeal penetration of thin liquids. There is no previous history of significant pulmonary problems.

Past Medical History: Narcolepsy and osteoarthritis (hands)

Family History: Unremarkable for pulmonary disease.

Social History: This patient smoked one pack of cigarettes per day for 20 years and stopped approximately nine years ago.

Review of Systems: All other systems reviewed and were negative

Physical Examination: Chronically ill appearing woman in no acute distress.

Vital Signs: BP: 126/80  P: 88  R: 16  02Sat: 99% on room air

HEENT: Normal inspection of the nasal mucosa, septum and oropharynx.

Neck: Flexion of the neck with tonic deviation toward the right, tightening of the soft tissues noted on the right.

Respiratory: Clear to auscultation, percussion and palpation

Cardiovascular: Regular rate and rhythm, no murmurs, rubs or gallops

Abdomen: No tenderness, masses or hepatosplenomegaly

Extremities: No clubbing or edema, cyanotic changes of the feet

Lymph Nodes: No cervical or supraclavicular adenopathy

Skin: No rashes, lesions or ulcers

Musculoskeletal: Normal muscle strength, tone and gait

Neuro: Alert, oriented with normal mood and affect

Laboratory Data:. Lucille Iacovelli: Complete pulmonary function studies performed at the Emerald Physicians office on 2/23/02 was normal with no evidence of airway obstruction, restriction or diffusing : abnormality. Spirometry today shows some obstruction although this was likely an effort related phenomenon. Chest x-ray from October 2003 showed hyperinflation but no acute cardiopulmonary disease.

Assessment:. Positional upper airway obstruction secondary to post surgical changes within the neck following a deep plane facelift. The patient’s history is quite convincing for episodic obstruction of the upper airway when her neck is extended and head positioned in the midline. **Her ENT physician in Boston requested fluoroscopy of the upper airway to help document this obstruction. I will make arrangements with the radiology department at Cape Cod Hospital to obtain the appropriate images. I do not suspect any significant parenchymal lung disease given the normal pulmonary function studies two years ago. Hyperinflation on chest x-ray is likely secondary to the patients thin body habitus. I have not scheduled the patient for a follow visit at this time but would be happy to see her back again in follow-up as needed. Thank you for allowing me to see this patient.

Sincerely,

Timothy Herrick, M.D.

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*Note:  A recent PFT (Pulmonary Function Test) performed in Dr. Herrick’s office indicates an upper airway obstruction at a level above the larynx.  This is the tongue pulling down.

**Dr. Herrick tried to schedule the airway fluoroscopy at Cape Cod Hospital but was told to send me “back to the surgeon in Boston” as he can instruct the radiologist about what  he wants visualized.  Dr. Herrick is correct.  It stands to reason that the surgeon should order the test and even be present to properly assess the problem.  Yet the surgeon I consulted repeatedly  refused, saying a pulmonologist should order the fluoroscopy. My breathing problem is NOT pulmonary, but a derangement of soft tissue that an ENT/head/neck surgeon should be able to evaluate, yet the surgeon who appeared in the HBO documentary with me has found numerous excuses not to perform an adequate physical examination or order appropriate diagnostics.  Dr. Herrick did everything possible within the realm of his specialty to help and guide me to the proper specialist.

While the doctors performing these studies and reporting their evaluations believe the findings significant,  the very surgeons who are supposed to be  most knowledgeable in this area of anatomy continue to dismiss or ignore this evidence.