[DYSPHAGIA] voice patient case query dislocation

[kgoertz@pahd.sk.ca (Clarke-Goertz, Kim (PAHD))]

Dear group members (apology-in-advance: rather lengthy post),

I have a patient I would like some input on.

He is a 41yo male with a nonsignificant medical history, other than + for
hep b and c.  He was involved in an assault approximately 9 months ago
following which he experienced mild (mostly resolved) cognitive deficits
(memory and attention) and a change in voice quality and intensity.  He had
dysphagia which has all but resolved, leaving a throat clear immediately
following thin liquids.  When asked, he reported that food occasionally gets
stuck (e.g., apples), but a liquid wash clears it.

He has had no aspiration complications that are of concern, however, his
voice continues to be low volume/too soft and rough/hoarse in quality. 

ENT saw him one month ago (did not get in sooner d/t patient was slow in
making appointment; he felt his difficulties would clear up on their own).
ENT reported normal VF movement bilaterally with no signs of trauma.

He does clear his throat frequently (less so since we've been working on
awareness and replacement of same with a milder throat clear/swallow or
hum); with less frequent clearing, I do not note any improvements in quality
or volume of his voice.  He has complained of pain in his throat, but not
consistent or specific.  He reports worse voice in the morning and later
evening.  I cannot seem to identify any overt abusive behaviors other than
the throat clearing and the fact that he smokes (4 cigarettes/day).  We have
discussed vocal hygiene in terms of increasing water intake, limiting
caffeine/dairy intake, reducing time spent in smokey environments, limiting
intake of very cold beverages, using a humidifier.  His MPT is 6-8 seconds
and his volume would be considered 'soft' affecting intelligibility with
background noise.  

I have not seen enough of a difference in this man's voice that makes me
think we are attacking the source of the problem.  My hypothesis thus far
(since seeing him in acute care after his assault) has been that he
experienced some irriation post-intubation, began throat clearing (further
complicating the original problem) and has not recovered since.  Lately with
less throat clearing (at least in my presence), I'm beginning to consider
the possibility of an external trauma  (e.g., dislocated cricoarytenoid or
cricothyroid joint).

When I asked him re: a snapping sensation in his neck and/or any pain
radiating up to his ear, he reported his neck will 'snap' at times  in the
back with sudden head turning.  I read that this is a possible symptom of a
dislocated arytenoid/thyroid, so I asked.  

I called ENT and asked him to see this man again.  He agreed he would in the
next couple of weeks.  I shared my suspicions re: laryngeal trauma (because
this gentleman was assaulted, more specifically kicked in the head/neck
region at the time of this injury).  

Have any of you who work with voice on a regular basis observed this type of
pattern (poor return of volume/quality 9 months post-this type of injury)?

What else should I be looking for?

Could it just be the throat clearing long-term contributing to his voice
problem?  His voice has not changed since I saw him acutely btw.

Also, our ENT here only has a flexible nasendoscope, no video.  Will that
suffice to pick up a dislocated joint?  

Thanks for any and all responses.

Oh, btw, I did try yawn-sigh and pushing to see what effect they would give,
and none was shown.  However, neither were done repeatedly-I don't feel
confident trying much of anything until ENT re-examines him.

Thanks all.

Kim

Kim Clarke-Goertz CCC-SLP (C)

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