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Modified Mondays: That doesn’t look right…

When completing an MBS study, the first thing I do is get a good baseline/scout image and give it a quick look over, checking to make sure my image is clear, that I have an unobscured view of the vital parts, and check any calcifications so that I don’t later mistake them for barium. ASHA and the American College of Radiology are very clear that part of the purpose of the MBS study is to assess the anatomy of the swallowing mechanism, and having a good idea of what your patient looks like before you really get into the barium and all the physiology and moving parts helps us do just that. The trick is, know what it SHOULD look like is the first step to know when something… is different.

This patient is really interesting, not just because we found something pretty rare, but also because it was his third MBS and it had never been picked up (per the patient, the medical hx in the chart, and the prior documentation). Take a close look at the hyoid. You will see what kind of looks like TWO hyoids. One that looks like the horns run straight back, as somewhat expected, and the second seems to head up and back at about a 45 degree angle. This patient was also complaining of severe pain with swallow and felt like food was “stuck” in there all the time. He had lost weight because of the pain. Because I know my anatomy, I knew the upward sweeping bit was where the stylohyoid ligament should be, I just had never seen one that clearly on fluoro. I asked the Radiologist to comment, and the report on this patient suggested Eagle Syndrome-one part of which is calcification of the stylohyoid ligament, which is what we are seeing here. He was referred to an ENT for further assessment.

The really dark side to missing something like this… is that the patient had been seen for therapy for several weeks now, working on pharyngeal contraction and base of tongue retraction to clear the “residues”, which was unnecessary. The really really dark side is the potential that the patient complaints could have easily been written off as psychosomatic.

Know what you are looking at (and what to do about it) is a critical piece of a comprehensive instrumental assessment.

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