[Dysphagia] question about voice

[ajbennett05 at yahoo.com (Jonathan Bennett)]

I know this is a little off topic, but I thought you all would have some good suggestions.  Sorry for the length:
   
  I have a patient that recently came in referred to me by the ENT for a voice eval.  He is an 81-year old man that came in with c/o dysphonia and decreased vocal intensity.  He was recently at the ENT, who scoped him.  The results of the scope were unremarkable. After numerous visits, the ENT was unable to state what the problem was and told him "not to worry about it". Medical history included, a 4-way bypass, h/o prostate cancer with resection, and h/o thyroid cancer with resection.  Patient with NO KNOWN h/o stroke, neurological disease, or respiratory problems.  Patient and wife state that voice comes and goes.  He can go for weeks at a time and voice will be fine, then all of a sudden he has a bad stretch.  Results of my evaluation showed (I have limited access to computerized diagnostics unfortunately): s/z ratio of 4.0, unable to phonate /ah/ on command...very breathy, frequent breaks in phonation during during conversation to me, and decreased pitch range. 
 Phonation time of /ah/ increased to 5 seconds when pushing or pulling on chair.  He came back to me today, which is 3 weeks later (due to some insurance issues), and his voice was much stronger during conversation.  Still breathy, but able to phonate /ah/ for 13 seconds when given to direction for abdominal breathing.  Voice was still not completely normal, but a marked changed from initial evaluation.  The wife says that this is what happens...gets better, then worse again.   Oh, patient also c/o dysphagia with food feeling "stuck" in throat.  A MBS was done on the patient about a month ago and no major structural problems seen.  No aspiration seen on the video, no reflux, Zenker's, etc.  Pyriform sinus and vallecular retention WAS seen though. According to the wife there is no pattern to when the dysphagia comes and goes and says it does not come and go at the same time the dysphonia does.  Also, they stated none of this started at the same time as any of his surgeries.
   
  I'm not quite sure where next to go.  The ENT doesn't seem to think there is anything wrong.  I know that Thyroid meds cause some issues with the muscles, but I don't know why it would come and go so frequently then.  ANY advice would be appreciate.
   
  Thank you

 				
---------------------------------
Get your own web address for just $1.99/1st yr. We'll help. Yahoo! Small Business.