International Journal of Clinical Case Reports 2015, Vol.5, No. 34, 1-5
4
dilatation in the right posterior communicating artery
with a very small aneurysm, and changes in the brain
due to small vessel disease with age. Based on the
patient’s clinical history and imaging findings, left
extracranial ICAA was diagnosed.
The patient underwent surgery 2 days after admission.
Endarterectomy of the left common carotid artery
(CCA) and external carotid artery (ECA) and
aneurysmectomy of the ICA were performed. Since
the glossopharyngeal nerve was adhered to the wall of
the aneurysm, the aneurysm surrounding the nerve
was cut and reconstructed with a Gore-Tex graft. Left
CCA-to-ICA/ECA bypass grafting also was performed
successfully. The patient’s dysphagia failed to
alleviate, and she developed aspiration pneumonia on
the third day after surgery. A nasogastric tube was
inserted for nutrition supply, and follow-up nasoph-
aryngoscopic examination, performed 10 days after
surgery, revealed salivary stasis in both pyriform
sinuses, especially on the left side, but no focal lesion
(Figure 3). Under suspicion of dysphagia due to CN
dysfunction, she was referred to the rehabilitation
department for ST, and was discharged from the
hospital.
General physical examination of the patient’s face
conducted in our outpatient clinic showed normal
results. A surgical suture line on the left side of her
neck was found. Comprehension was normal. CN
examination revealed mild dysarthria and dysphonia,
dysphagia resulting in nasal regurgitation and cough
Figure 3 Nasopharyngoscopic image, showing salivary stasis in
both pyriform sinuses, especially on the left side
after the patient swallowed, weakness of the left
pharyngeal wall with mild deviation toward the right,
the tongue slightly deviated toward the left during
protrusion, and suspected paralysis of CNs IX, X, and
XII. Clinical BSE demonstrated oropharyngeal
dysphagia (Table 1). She could not pass the 100-mL
water test and was at level 1 of the FOIS.
Traditional ST methods were used, including oral
exercise, position adjustment (by turning the head to
the left) in order to close the weak pharynx,
swallowing maneuvers, and diet modification. Since
no improvements were noted after 2 weeks (4
sessions), we decided to add NMES to traditional ST.
The Intelect VitalStim NMES machine (Chattanooga
Group) was used (current model, discharge current;
current intensity, 0-25 mA; pulse period, 100-300 μs;
pulse rate, 80 pps). Two electrodes were placed in a
vertical line on the right side of the neck, lateral to the
midline, with channels 1 and 2 just above and below
the thyroid nodes, respectively. The current intensity
was such that the patient felt a “grabbing sensation,”
indicating that the correct level of motor contraction
had been reached. The stimulator was left at this level,
and then ST was initiated. The patient had two 1-h
training sessions each week.
Author’s contributions
The roles of the authors in this case report are as follows: FCL
– first author, manuscript writing; F.Y.L. – The patient’s
surgeon, providing the patient’s source and data; X.R.D. – The
patient’s speech therapist, providing the swallowing training to
the patient; C.P.L. – corresponding author, management of the
study. All authors read and approved the final manuscript.
Acknowledgements
We would like to thank Department of Physical Medicine and
Rehabilitation of Kaohsiung Chang Gung Memorial Hospital
for their assistance with treatment place and materials.
References
Altin G., Sanli A., Erdogan B.A., Paksoy M., Aydin S., and Altintoprak N.,
2012, Huge Internal Carotid Artery Aneurysm Presenting as Tonsillar
Asymmetry, Journal of Craniofacial Surgery, 23: 1565-1567
Biasi L., Azzarone M., De Troia A., Salcuni P, and Tecchio T., 2008,
Extracranial Internal Carotid Artery Aneurysms: Case Report of a
Saccular Wide-necked Aneurysm and Review of the Literature, Acta
Biomedica, 79: 217-222
Burnett T.A., Mann E.A., Cornell S.A., and Ludlow C.L., 2003, Laryngeal
Elevation Achieved by Neuromuscular Stimulation at Rest, Journal of
Applied Physiology (1985), 94: 128-134
