International Journal of Clinical Case Reports 2015, Vol.5, No. 34, 1-5
3
involving turning her head toward the left (affected)
side to close the weak pharynx and prevent choking,
as well as training to modify posture during swallowing.
Evaluation of the patient’s swallowing ability was
performed using BSE, FOIS, and the 100-mL water
test. We elected to not perform videofluoroscopic
swallowing assessment before treatment due to the old
age of the patient and because her severe dysphagia
caused her to choke when she consumed food of any
consistency. While recovery of our patient after
combination NMES and ST was remarkable, this case
raises a few questions that can only be resolved with
further study. For example, we performed NMES and
ST twice every week, and whether more intensive
treatment would have reduced the treatment course is
unknown and worth investigating. Further, it is important
to note that the decision to apply combination therapy
was made 6 weeks after surgical intervention, when
the patient showed no signs of recovering from
dysphagia. It is possible, however, that resolution of
the nerve palsies would have spontaneously occurred
later. As such, the specific contribution of the
therapeutic strategy employed remains to be determined.
In conclusion, the findings of this case demonstrate
the efficacy of combination NMES and ST in the
treatment of dysphagia that developed in a patient
diagnosed with a giant left ICAA. As such, this
therapeutic approach may have a positive clinical
rehabilitative effect, but further studies will be required
to assess its long-term effects.
4 Materials and Methods
A 99-year-old woman was referred to our rehabilitation
department for dysphagia evaluation and therapy. She
had managed hypertension for many years with
regular medication. She had been diagnosed with
cervical cancer 4 years before admission, and also had
a left femoral neck fracture due to an accidental fall 1
year before admission. Besides this, she denied a
history of other systemic disorders, head and neck
trauma, or stroke.
The patient first visited our otolaryngologic outpatient
clinic for assistance with a mass on the left side of her
neck that had been gradually growing for approximately
1 year. She also had developed progressive dysphagia
over several months to the point that she could only
swallow a small amount of water. Initial nasopharyn-
goscopic examination revealed posterior pulsatile
masses on both sides of the oropharynx. The nasal
cavity, nasopharynx, oral cavity, hypopharynx, and
larynx were otherwise unremarkable. Head and neck
computed tomography was performed under the
impression of the aberrant carotid artery, which
revealed a giant left proximal ICAA (4.7 × 3.4 cm)
near the carotid bifurcation (Figure 1). She was
transferred to the cardiovascular surgery department
for surgical assessment.
On admission, the patient had no signs of fever, chest
tightness, nausea, vomiting, abdominal pain, dysuria,
heartburn, muscle weakness, or neck bruits. Head and
neck magnetic resonance imaging and magnetic
resonance angiography confirmed a 4.5 × 3.5 ×
3.5-cm giant ICAA in the left parapharyngeal space
(Figure 2). Findings also demonstrated an unsaturated
flow signal in the left internal carotid artery (ICA)
distal to the aneurysm on the neck, an infundibular
Figure 1 Computed tomographic images of the head and neck,
showing a giant left proximal internal carotid artery aneurysm
(4.7 ×3.4 cm) near the carotid bifurcation
Figure 2 Magnetic resonance angiographic images, revealing a
giant internal carotid artery aneurysm (4.5 ×3.5 ×3.5 cm) in
the left parapharyngeal space
