Modified Mondays: A Case of Mistaken Identity?

I’ve always wished that an MBS study could be in color somehow, mostly just because it would be cool… but also because since everything shows up in shades of black and gray, it can sometimes be difficult to discern between aspiration and …. things that actually belong in the neck.

This clip is great example of a possibly mistaken identification. The patient had recently been transferred to a SNF from an acute care hospital, her original diagnosis was a fall with subsequent hip fracture, had some deconditioning, wasn’t eating very much, complained a bit about difficulty swallowing, and had an MBS at the hospital. MBS report cited “persistent aspiration at posterior airway, with all consistencies, patient unable to clear” and recommended NPO. Patient refused, was “allowed” to keep eating, arrived at the SNF, and was promptly referred to the SLP, since she was eating and drinking AMA. Thankfully, the SNF SLP was a bit skeptical of the NPO recommendation, since the patient had no history of any lung status changes, and had continued to be CTA, despite eating and drinking while aspirating “all consistencies”.

We completed the MBS and noted a perfectly beautiful swallow-as well as calcification in the arytenoid areas that looked a heck of a lot like aspiration at the posterior airway. Now, let’s be clear. The patient could have been aspirating all consistencies on the prior MBS and spontaneously recovered. However, it’s worth considering that the calcification was mistaken for aspiration. In fact, calcification is sometimes mistaken for a foreign body by Radiologists, so it’s not like it’s just us making errors out there.

It’s really important to take a baseline look at the patient before introducing the barium to discern was is new and what was already there. Many laryngeal structures can become calcified and eventually ossify over time-it happens to most of us as we age, starting around the third decade of life, with men typically developing it more extensively than women. Ossification is usually symmetrical, so it can be easier to identify by asking the patient to turn their head to the side a bit and looking for a matching shape. Not as easy if the MBS was nice and colorful, but still.

Further reading:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5530299/

https://anatomy.elpaso.ttuhsc.edu/clinicalcases/laryngeal_ossification/case.html