Irene Campbell-Taylor, MB ChB, PhD

A 74 year old woman with complaints of food “sticking” in her throat.

This is a dramatic example of a pseudotumor, so called because, if a flat film were made at the point of extreme extension, it would probably be mistaken for a tumor. The anterior bulging of the pharynx seen developing is common in long standing dysphagia, possibly as an attempt to protect the entrance to the airway which is normally accomplished by contact between the arytenoids and the base of the epiglottis. It is presumed to be achieved by extreme tension of the pharyngeal constrictor muscles. It is interesting that, although aspirating constantly for many years, this woman never developed any respiratory disease/infection although it is mistakenly assumed that any and all aspiration will lead to pneumonia. The facts are these: Aspiration pneumonia, as distinct from aspiration pneumonitis, occurs in the following circumstances:

4. Most importantly, the condition of the patient’s immune response. 

All four variables must be considered together.

The cause of this patient’s dysphagia was the adverse effect of 30 years of psychotropic medications including antipsychotics, well known to negatively affect swallowing. In this case, because of no history of respiratory involvement, there was no need to change or restrict her intake. Reassurance with respect to her fear of cancer was sufficient.

(Please note: This is not an example of the more common inflammatory pharyngeal pseudotumor.)

1. Rudolph JL, Gardner KF, Gramigna GD, McGlinchey RE. Antipsychotics and oropharyngeal dysphagia in hospitalized older patients

2. Sokoloff LG1, Pavlakovic R. Neuroleptic-induced dysphagia. 

3. Gonzalez F. Extrapyramidal syndrome presenting as dysphagia: a case report. 

 Edition.Mahmood F. Mafee , Galdino E. Valbasson, Minerva Becker, J S Lewin (Eds) 2004. Thieme Publishers 2004.

Poll

74-year-old woman complains of food “sticking” in her throat.

Image IQ: Food “Sticks” in Throat

A 74-year-old female presented with multiple, soft swellings around the knees and upper thighs. These had developed slowly over five years and were extremely tender to pressure. Standing and walking was increasingly painful. Marked fibromyalgia was also identified

Answer: Juxta-articular adiposis dolorosa (Dercum’s Disease)

On physical examination, the patient was found to have extremely tender fatty areas around both knees and over both hip joints. She was moderately overweight with a BMI of 27. She had a waddling gait and described severe pain on standing and walking.

First identified by Francis X. Dercum, in 1892, Dercum’s Disease (also Adiposis Dolorosa) is described as, "A disease accompanied by painful localized fatty swellings and by various nerve lesions. It is usually seen in women." The cause is unknown.

Symptoms include pain in the fatty areas lasting for at least three months. The pain in fat and skin can be intense and is described as aching, stabbing, smarting, or burning. Swellings consisting of irregularly shaped soft fatty tissue may occur in many areas of the body. These deposits occasionally disappear, leaving hardened lumpy or rope-like tissue or pendulous folds of skin. The pain is chronic and progressive. It can exist in the entire fatty tissue layer, but most commonly affected are the knees, trunk, forearms, and thighs, sparing the face and hands. Severe weakness has been emphasized as a feature by some. The pain increases even at gentle touch, and massage is unpleasant. Other symptoms:

•Memory lapses and concentration difficulties

•Difficulty wearing tight fitting clothes or taking a shower

The pain seems to depend on the temperature and the weather, and decreases in dry heat. The pain can make it difficult to: walk, drive a car, turn a water tap, lift items from shelves, carry bags, open heavy doors, or perform all types of house care.

The cause is unknown. Dercum’s Disease is thought to be inherited as an autosomal dominant genetic trait, particularly strong in the line grandmother-mother-daughter. 

The radiologist is often the first person to identify the disorder although, knowledge about the disorder is not common and many patients may be misidentified. Weight loss has little or no effect on the symptoms. The classic physical sign is extreme pain when one of the fatty areas is squeezed.

MRI is the preferred instrumental examination. Ultrasound can add to the diagnosis with fatty areas appearing like lipomas but not firm and very painful when pressed. The fatty areas can be seen even in the weight bearing X-ray.

1. Berenguer B, de la Cruz L, de la Plaza R. Liposuction in atypical cases. 

2. De Silva M, Earley MJ. Liposuction in the treatment of juxta-articular adiposis dolorosa. 

3. Hansson E. Liposuction in Dercum’s Disease. Clinical Studies Regarding Dercum’s Disease and the Effect of Liposuction. Monograph: Department of Clinical Sciences in MalmÃ¶ Lund University. Plastic and Reconstructive Surgery.  2011 SkÃ¥ne University Hospital, MalmÃ¶, Sweden.

4. Tins BJ, et al., Adiposis dolorosa (Dercum’s disease): MRI and ultrasound appearances. 

http://dx.doi.org/10.1016/j.crad.2013.05.004

74-year-old female presented with multiple, soft swellings around the knees and upper thighs. 

Image IQ: 74-year-old Female, Soft Swellings Around Knees, Thighs

Speech Language Pathologists (SLPs) present themselves as experts in the identification and management of oropharyngeal dysphagia despite having no background in medical sciences or radiology. Training is almost entirely classroom/textbook-based or from others who are also poorly trained. The Videofluoroscopic Swallowing Study (VFSS) is used frequently, whether or not required, and is relied upon for recommendations for patient treatment that are then performed by physicians who believe in the expertise of SLPs.

Standards for the dynamics of swallowing were established in research by radiologists using barium alone. SLPs use barium mixed with food, which is not only of increased risk if aspirated, but is of a consistency unlike real food. Barium, if aspirated, is harmless and was used for years for bronchograms, injected directly into the lung mainly to identify tuberculosis. Mashed potatoes with barium is not even close to mashed potatoes alone, so the recommendations for types of food suitable for individual patients , based on materials used in VFSS , are invalid. Hospital food can be atrocious, but is unlikely to be improved by the addition of barium.[[{"type":"media","view_mode":"media_crop","fid":"28811","attributes":{"alt":"Irene Campbell-Taylor","class":"media-image media-image-right","id":"media_crop_9905308514310","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2945","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 248px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Irene Campbell-Taylor, MB ChB, PhD","typeof":"foaf:Image"}}]]

The claim that VFSS allows trials of compensatory strategies is affected by the same problem; the material used is totally unlike real food and we don’t eat in the half teaspoon or coffee spoon boluses used. Any indication of possible aspiration is often followed by a recommendation for thickened fluids, wrongly believed to prevent aspiration but known to cause dehydration leading to hypovolemia, orthostatic hypotension, falls, delirium, UTIs, constipation, decubiti, etc., especially in the elderly. Since we all aspirate some saliva every day, oral care is far more important than, say, aspiration of water.

Usually, lateral views only are done so that what’s going on in the other side of the mouth remains unknown. If AP views are omitted, one misses information, such as asymmetry of pharyngeal function, atrophy of the tongue, unilateral epiglottic failure, webs, and Zenker’s diverticula. Decisions about whether or not VFSS is necessary should depend on the results of the full clinical examination, which is seldom taught. Radiological examination would be required only if there were indications from the history such as tumor, diverticulum, web, or neuroleptic use with tardive dyskinesia among others.

The most alarming aspect of this situation is that very often the radiologist is not present during the study and signs the SLP’s report, sometimes due to the belief in its accuracy, but often because of a lack of interest in the area of oropharyngeal dysphagia. Morphological changes may be missed, sometimes with disastrous results. Inappropriate recommendations, especially for enteral feeding, are agreed to, diverticula and cervical osteophytes missed because the radiologist never looked at the study, which should always be reviewed in slow motion since the human eye is unable to identify all the elements of a rapid event such as swallowing.

It is suggested that the issues discussed here present a danger to the public that radiologists have a responsibility to correct.

Articles

Videofluoroscopy swallowing study standards were established in research by radiologists, but have been altered by SLPs.

Author | Irene Campbell-Taylor, MB ChB, PhD

Articles

Image IQ: Food “Sticks” in Throat

Image IQ: 74-year-old Female, Soft Swellings Around Knees, Thighs

The Radiologist-Speech Language Pathologist Disconnect