1/25. Interpreting a living will after stroke.Mr. Duffy is 83 years old and is admitted to rehabilitation 4 weeks after a right thalamic cerebral vascular accident (CVA). He has dysphagia, dysarthria, left hemiplegia, and is moderately-severely confused. He pulls out his nasogastric feeding tube and his physician decides not to reinsert it because of significant nasal tissue necrosis. The team recommends a gastrostomy tube for nutrition because of Mr. Duffy's lack of alertness and high risk for aspiration. Mr. Duffy has a Living Will that states he does not wish to have his life sustained with a feeding tube. He does not have a formal Durable Power of Attorney for health Care. His wife has dementia and their daughters are making decisions for both parents. They are not sure about his wishes in this particular circumstance, but report that he said of a relative who died of cancer, "things went on too long because of that feeding tube." After 3 days, Mr. Duffy is more alert, and during a discussion about tube feedings he says, "I'll go for the works." His fluctuating alertness level prevents him from responding to this question again. His daughters feel he would not want the tube and suggest waiting to see if his swallowing improves in the next week before making a decision.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/25. Bulbar presentations of myasthenia gravis in the elderly patient.We report on three cases of patients whose primary symptoms of myasthenia gravis were related to the upper aerodigestive tract. Symptoms had been present unrecognized in all patients for up to three years, and one patient subsequently developed a myasthenic crisis. We highlight the clinical features of myasthenia gravis to allow its prompt recognition in patients presenting to the ENT surgeon or physician.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/25. osteophyte-induced dysphagia: report of three cases.Dysphagia is a common complaint of patients seen by physicians. osteophyte compression due to diffuse idiopathic skeletal hyperostosis (DISH) or Forestier's disease and cervical spondylosis has been identified as a cause of dysphagia. We report three elderly male cases of whom two had dysphagia due to DISH and one had dysphagia due to osteophyte compression associated with severe cervical spondylosis. Clinical and radiographical findings including barium oesophagogram and computed tomography are presented. endoscopy should be carefully performed to rule out additional pathology in such patients. Medical treatment preferably with liquid forms of NSAIDs and diet may cause satisfactory improvement.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/25. High-altitude decompression illness: case report and discussion.decompression illness (DCI) can occur in a variety of contexts, including scuba diving and flight in nonpressurized aircraft. It is characterized by joint pain, neurologic injury, and respiratory or constitutional symptoms. To prepare flight crews for accidental decompression events, the Canadian Armed Forces regularly conducts controlled and supervised depressurization exercises in specialized chambers. We present the cases of 3 Canadian Armed Forces personnel who successfully completed such decompression exercises but experienced DCI after they took a 3-hour commercial flight 6 hours after the completion of training. All 3 patients were treated in a hyperbaric oxygen chamber. The pathophysiology, diagnosis and management of DCI and the travel implications for military personnel who have undergone such training exercises are discussed. Although DCI is relatively uncommon, physicians may see it and should be aware of its presentation and treatment.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/25. rehabilitation medicine: 2. diagnosis of dysphagia and its nutritional management for stroke patients.Following stroke, patients may have reduced dietary intake, swallowing impairments (dysphagia) and other neurological deficits that could affect their nutritional and hydration status and lead to aspiration pneumonia. Impaired nutritional status is associated with reduced functional improvement, increased complication rates and prolonged hospital stays. This article is aimed at primary care physicians and others caring for stroke patients. We discuss the need for assessing the nutritional status of stroke patients and provide strategies for the management of dysphagia and patients' food and fluid intakes. In addition, we review clinical and radiological options for the diagnosis of dysphagia as well as oral and enteral feeding alternatives.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/25. Prolonged effect of botulinum toxin injection in the treatment of cricopharyngeal dysphagia: case report and literature review.Cricopharyngeus (CP) muscle spasm can lead to severe dysphagia. Myotomy of the CP muscle was the treatment of choice. Recently, botulinum toxin type A (BtxA) has been used for CP spasm. It usually brings improvement in deglutition but most patients require reinjection in 3-5 months. We report a 35-year-old man who had an arteriovenous malformation hemorrhage in the brain stem resulting in CP spasm and consequently severe dysphagia. He received BtxA injection and deglutition and nutrition remained good one year after treatment. A literature review analyzing 28 patients and our patient showed negative correlations between age and BtxA dose and between age and duration. Efficacy was positively correlated with duration and BtxA dose was positively correlated with pretreatment severity. In conclusion, physicians would use higher doses on patients with more severe cases but use lower doses on older patients. Those who obtained better post-treatment results would enjoy longer effective duration. Thus, the effective duration of the BtxA is multifactorial.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/25. Dysphagia aortica: a neglected symptom of aortoesophageal fistula.Aortoesophageal fistula, secondary to thoracic aortic aneurysm, is an uncommon cause of gastrointestinal bleeding that is uniformly fatal without surgical intervention. Typical symptoms are midthoracic pain and/or dysphagia followed by a usually short, albeit unpredictable, symptom-free interval and by a 'herald' haemorrhage, which is observed in 80% of patients before fatal exsanguinations. Dysphagia is present in 45% of patients, sometimes for several weeks, before the first bleeding occurs. However, dysphagia aortica is rarely considered in the differential diagnosis of dysphagia and lack of awareness, as well as symptom's underevaluation, both contribute to a significant diagnostic and therapeutic delay. We present a case of a 77-year-old woman who died for a bleeding AEF consequent to a thoracic aortic aneurysm and whose main symptom during the past 2 months was dysphagia, which was not taken seriously into consideration by her general practitioner. This case report emphasises that primary care physicians should be alerted to evaluate carefully the alarming symptoms like dysphagia -- especially in elderly patients -- before life threatening complications occur, as they are the ones who could suspect early the diagnosis and make a proper referral.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/25. aphonia and dysphagia after gastrectomy.A 67-year-old male was referred to our otolaryngological clinic because of aphonia and dysphagia. His voice was breathy and he could not even swallow saliva following a total gastrectomy for gastric carcinoma performed 2 weeks previously. Laryngeal fiberscopy revealed major glottal incompetence when he tried to phonate. However, both vocal folds abducted over the full range during inhalation. The patient could not swallow saliva because of a huge glottal chink, even during phonation. Based on these findings, he was diagnosed as having bilateral incomplete cricoarytenoid dislocation after intubation. The patient underwent speech therapy; within 1 min his vocal fold movement recovered dramatically and he was able to phonate and swallow. There have been few case reports of bilateral cricoarytenoid dislocation, and no effective rehabilitation has been reported. We believe that our method of vocal rehabilitation serves as a useful reference for physicians and surgeons worldwide.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
9/25. Videoendoscopic evaluation of patients with dysphagia: an adjunct to the modified barium swallow.The modified barium swallow is currently the most comprehensive, widely available, and easily interpreted technique for the evaluation of patients with dysphagia by the head and neck surgeon. However, it requires the facilities, personnel, and use of a radiology suite, a trained speech pathologist, and exposure of the patient to radiation. It would therefore be helpful to have an adjunctive, physician based, nonradiographic method of examination that could provide information similar to and possibly even more complete than that supplied by the modified barium swallow. Such an adjunctive method could help otolaryngologist-head and neck surgeons confronted by a new patient with swallowing difficulties to orient themselves to the nature and severity of the problem while waiting for the modified barium swallow to be scheduled, performed, and reviewed. It could also be a helpful tool for management of patients with cancer of the head and neck, whose swallowing function may change rapidly in the early postoperative period. In such cases, intervals between modified barium swallow examinations (dictated by concern over radiation exposure) may be too far apart to allow up-to-the-minute decisions on case management. Finally, some patients who may be too ill to travel to the radiology suite might benefit from a bedside procedure that would yield information about swallowing function similar to that provided by the modified barium swallow. Videoendoscopic evaluation of dysphagia (VEED) is a protocol I developed and have used regularly since 1984. Experience with this method of dysphagia evaluation has shown that it answers the needs outlined above. Its usefulness also goes beyond that of the modified barium swallow by providing a more detailed understanding of the component anatomic and functional deficits that comprise a given patient's swallowing problem, information about upper aerodigestive tract sensory deficits, and a means for visual feedback training of pharyngeal and laryngeal musculature. The protocol is reviewed here. case reports illustrating the clinical usefulness of VEED as an adjunct to the modified barium swallow are also presented, and the relative strengths and weaknesses of VEED and the modified barium swallow are compared.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/25. Gastrointestinal manifestations of epidermolysis bullosa in children.The medical and surgical management of the chronic and recurrent esophageal and anal lesions of recessive dystrophic epidermolysis bullosa pose challenging problems for the physician. Various therapeutic approaches are discussed, and the case histories of four problem patients are reviewed.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
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