This week I want to share an interesting case study. This is about a patient that I saw when I was previously working in acute care. Diagnostics there were video fluoroscopic imaging, not FEES, but we know it’s never FEES versus VFSE. It’s FEES and/or VFSE.
The patient was a 65 YOM who just completed ACDF. I apologize that I don’t remember the exact details of the surgery. This patient was complaining of pain and difficulty with swallowing. On first thought, we know that almost everyone who has this surgery will have temporary difficulty with swallowing due to edema, however, this seemed more severe than most cases.
I went and saw the patient, and like I said most patients have some edema, but this gentleman had major edema. On the right side, you could not see where his chin ended and his neck began. In consultation with the care team, the doctor reported he had already finished his course of steriods.
During the interview, the patient reported that he felt like he could not swallow anything and when he took a small sip, he felt like it was “going the wrong way” and it made him cough every time. He also reported after he swallowed that he felt pain in his neck. When I asked where the pain was, the patient pointed to his neck lateral to midline. He described the pain as a burning sensation. He said it really only burned after he swallowed.
The patient completed an oral motor examination and the only significant finding was the edema. With oral trials, the patient did demonstrate immediate coughing regardless of consistency. No regular solids were attempted as the patient was on a full liquid diet per medical team. With sips of thin liquids, the patient swallowed up to six times, coughing in-between swallows, and breath quality was wet. At this time, I made the recommendation for a VFSE. Unfortunately, this referral came in late in the day and the VFSE would not be completed until the next day.
The VFSE revealed internal edema which restricted bolus flow and caused aspiration. This was not surprising based on his clinical appearance. Positioning changes were ineffective in improving bolus flow. The patient completed three trials of thin liquids when the cause revealed itself. Contrast began to show up lateral to the pharynx, right where the patient said that he felt the burring. He had a fistula from the surgery. He was quickly taken for a CT scan and then flown to a higher level of care.
So while this case is very interesting, I think it also sheds light on the importance of instrumentation. Had I just assumed it was the “regular” swelling from the surgery, the fistula may not have been discovered until later, when there could have been serious consequences. Now, I am not of course saying every ACDF patient needs imaging, but when there are unique symptoms, imaging is always the best choice.
What unique cases have you encountered? What incidental findings have you seen?