hello my name is dr earl nicholas todd or dr ent
i am an otolaryngology head and neck surgeon i will be reviewing scenes from a few different tv
shows including limitless hannibal and grey's anatomy that contain ent relevant materials
let's first take a look at the scene from the tv show limitless here we go
the main character swallows a special pill which is then shown being swallowed via an
x-ray technique called fluoroscopy as it pertains to swallow the test is specifically called a
modified barium swallow and is used to actually help evaluate patients who have trouble swallowing
the main problem with this particular scene is that when a pill is swallowed
one should only see the pill the black material around the pill should not be present
now that said i suspect if the black material was not present it would be much more difficult
for the tv viewers to see the pill going down as such creative liberties were certainly taken here
in this scene from hannibal the vocal cords shown are totally accurate and is actually
what one see when using an endoscope the error in this particular scene occurs as the viewpoint
moves from the voice box and out the mouth what is actually shown just before one sees the mouth is
that the view goes into the back of the nose before it seamlessly merges into the mouth
why does it do that because when endoscopy is performed to look at the vocal cords we always
go through the nose i should also mention that the vocal cord movements do seem to sync up with
the singing but the breathing and heartbeat sounds typically are not heard so obviously
why were you rushing to the er oh because the fish
there's a fish inside of there what like like part of a fish or a bone or an entire fish sir
interesting if the character swallowed an entire fish but it got stuck in his throat in the
region known as the upper esophageal sphincter it certainly is possible he may have trouble talking
and the unusual breathing sounds he is making is certainly plausible as well as
the airway may be partially obstructed what happened exactly the bar had an aquarium
all right so we winded down chuck's bachelor party you know what i'm saying this is bachelor party so
we start daring each other to swallow fish from the aquarium you know how it is end of the night
yeah no okay i honestly worry of your entire gender sometimes anyway he grabbed the biggest
one we didn't think he was gonna do it we like he ain't about to do it he guffs the whole damn
fishing i guess the fish didn't like that so the fish start fighting back start slapping
just start going crazy it goes in deeper deep we tried to pull it out it would not come out
and then it kind of puffed up that doesn't sound like a goldfish
yeah no i'm flirting with this x-ray this thing's got spikes and then i got scared
because i thought he was gonna choke our pew or that the fish could be poisonous
it now becomes apparent why the patient is having trouble talking the spikes have probably impaled
the muscles of the voice box preventing the vocal cord movement thereby resulting in a functional
vocal cord paralysis the main concern i have medically beyond the stuck fish is the potential
traumatic swelling that may eventually result in airway obstruction also you have got to be worried
about infection that the mucosa is certainly punctured if not torn if torn the patient also
has an esophageal perforation which can lead to severe infection not just in the throat region
but also around the heart as well as lungs craziest dumbest things a person can do
the er is just like holding my beard maybe he had it's fortunate they were able to intubate
the patient if not an emergency tracheostomy would have to be performed also a scope was
used to retrieve the fish which is not wrong but it would not be the easiest method an easier and
better method would be to widely open the throats using a laryngoscope like a weirdo or adido rigid
instrumentation would then be used to retrieve the fish as anybody who works with fish or likes
to fish nose the fish skills are oriented in such a way that pulling a fish backwards would result
in the scales catching on whatever is touching it like barbs this would make retrieval not only
more difficult but would also result in further mucosal lacerations during the removal process
indeed removal will probably result in way more damage than when the fish got stuck during swallow
i managed to remove all the spines you're likely going to experience some discomfort
on your throat for the next few days and your hand is repaired but i need to have you follow
up with me in a couple of weeks hey so you guys you guys are smart your doctors right
the patient unrealistically looks and talks way better than he should immediately after surgery
realistically he would have been kept intubated for a prolonged period of time
probably a few days to allow any swelling to resolve but also to limit any soiling to the
damaged mucosa i probably would have a feeding tube surgically placed through the abdominal wall
as the patient would be kept npo for days if not weeks to minimize infection given likely presence
of an esophageal perforation regarding his voice i would have expected it to be extremely hoarse
but um more importantly huh how are you doing oh i just had a little bump on my tongue removed us all
a couple of taste buds turns out it was a little touch of cancer so i'm here to have the rest out
i mean you know the cancer not the taste buds i don't know exactly how bad it is because dr
sloane over there has been awfully quiet cause you don't let him get a word in edgewise is why
uh how is he dr flow we just got back the pathology of cor connie unfortunately the
cancer is a bit more widespread than we'd hoped it's over 60 percent of your tongue the patient
apparently has been diagnosed with tongue cancer the most common type being squamous cell carcinoma
although you can diagnose tongue cancer with a biopsy you cannot determine the cancers
involving sixty percent of the tongue with a biopsy alone the cancer size and involvement
can only be determined based on an exam and imaging studies like a ct mri or pet scan
also if sixty percent of the patient's tongue is truly cancerous she would often be in a lot
of pain as well as having trouble talking either due to large tumor involvement or nerve invasion
resulting in tongue paralysis trouble swallowing is also common well what what does she do chemo
i think the uh best bet is a microvascular free flap dr gray uh he'll remove the cancerous part
of the tongue and then reconstruct it with a strip of flesh from your legs george uh the
extra flesh will provide the bulk your tongue needs to breathe properly chew swallow and talk
dr sloan i'll be able to talk when i you will be able to talk
i just don't know how well you'll be understood the information provided in this scene is spot
on a free flap is when soft tissue like skin and muscles move from one part of the body to another
and the blood vessels have to be reattached what is not mentioned is that there are other options
including a pedicle rotation flap from the chest head or neck in which the blood vessel's
integrity is kept intact rather than a free flap far from the surgical site also radiation
and chemotherapy is certainly an option as well with surgical excision a neck dissection would
also be performed to remove all of the lymph nodes in the neck due to possible metastases
regardless of treatment having a tracheostomy and feeding tube placed is common as there is always
some degree of postoperative swelling resulting in possible airway obstruction and the patient will
need to relearn to swallow and as such will need nutritional support during the recovery period
that's a perfect got good vascularization at this rate you may actually get to go on a date
with adele yeah i better can't very well have her take me back if i cancel our first date
where are you taking her chief oh there's a nice little chinese restaurant we like to go to hmm
what happens next um dr sloan i know is everything okay um
we're not sure what does that mean it means we've never done this before
it is hard to say exactly what the problem is that the surgical team encountered
i suspect that they were hoping to preserve the nerve controlling the tongue's movement
but that the nerve was involved with cancer and as such would need to be sacrificed
this would adversely affect speech and talking is what the patient most desired preserved
what about if we collapse the lingual nerve underneath here no we'd end up losing the
vascular supply graph might not work at she likes her talks a lot she likes to talk a lot
we need an extra set of hands someone who knows nerves old mallet good doctorship
functional muscle transfer of the tongue that was looking good for a while but
i'll be right there yeah here they are talking about ways to salvage nerve function to the
tongue which i honestly can't say is able to be possible especially if more than 60
percent of the tongue is removed of course dr shepard is consulted who understandably
is less than pleased with the idea of preserving nerve function with a free flap
that's because it realistically is not possible even if you grafted a new nerve at best you may be
able to restore a marginal partial movement after a one year but it will never be totally normal
speech will certainly be of poor quality and being able to swallow without aspirating will
be possible after a long period of recovery and therapy i think that woman's going to
be able to talk for the rest of her life thanks to us i think i still got it i think you do too
not sure why the original two surges are congratulating themselves when dr shepherd
is the one who actually saved the day though i personally am not quite sure how painful
going really well
after surgery the patient normally would be in the intensive care unit breathing through a trach
in this scene her face looks swollen but in reality the swelling would actually be even worse
overall the actors and producers did a great job recreating medical problems encountered in the ent
clinic certain facts and situations stretched belief and others were just completely wrong
but in spite of these misses it is still entertaining to watch