So everyone, this is Sameh Wu. He's one of our cancer rehab fellows and he'll be presenting a case today in a head and neck cancer patient. Great. So I'm presenting a case about a 52-year-old female. Her primary malignancy was papillary thyroid cancer. We saw her in an outpatient clinic originally in early February. She also had her past oncologic history. She had had a right hemithyroidectomy and thyroglossal duct cyst resection with otolaryngology back in 2021. Some of the interesting comorbid conditions she had, she self-reported a history of dealing with more than 20 years of thoracic outlet syndrome. She also mentioned she had a seronegative rheumatoid arthritis and Strogen syndrome. And in terms of her prior level of function, she was pretty independent. Husband helped her with more independent activities of daily living. She was working in administration in a doctor's office. So when we first saw her, the referral did come from ENT. So she was just complaining about upper neck and thoracic back tightness and pain since the onset of her thyroidectomy surgery. So this was bothering her on a daily basis. Some associated symptoms included some radicular pain down the right arm, more so in her C8-T1 distribution on exam and affecting her right arm more than her left arm. Also with some weakness with opening objects like bottles. And then she mentioned some intermittent vision blacking out episodes as well, which was concerning to us, hearing that kind of red flags going off. And then she mentioned this radicular pain down the arm was worse with overhead movements, more work at the computer and better with just resting. So when we first saw her on an exam, we were interested of course, in looking at her C-spine, her range of motion at the shoulder, what exacerbated her pain. And she presented like a lot of patients with kind of poor posture, just forward neck and protracted shoulders. There was some tenderness over her upper cervical, paraspinals, upper traps. Range of motion was pretty limited all throughout, but worse in lateral neck rotation. She had a negative Sperling's maneuver. And then we did some more specialized tests, which included the Adsens, which reproduced some of the symptoms she described in her right arm. And I'll get into some of the tests specifically in the next few slides. Also the rights tests as well, kind of reproduce some symptoms similar to what she was describing. Just inspection wise, we didn't see any swelling, discoloration, temperature change on palpation. The radial pulses were present bilaterally. There was some tenderness as well. So interestingly enough, she also had some right elbow pain, which we thought was probably just lateral epicondylitis. And then some pain over her chest wall on the right side, her pectoral muscles. Wrist extension was painful, especially with resistant wrist extension. A more dedicated shoulder exam, Hawkins for impingement was negative. She had a positive Cozen's as well for the right elbow pain. Pretty strong throughout, just some pain limited wrist extension, and then decreased sensation in her right fourth and fifth digits. And then the Hoffman's is negative bilaterally. So yeah, upon kind of gathering all of these history and physical findings, and with her self-reported history of thoracic outlet syndrome, we were concerned, of course, for progressive worsening of her known disease. She had also mentioned, those episodes of blacking out with her vision kind of blacking out. So I was concerned for any like arterial or vascular etiology as well, like a subclavian steel syndrome, where the contralateral artery kind of helps compensate with blood flow, given there's some impaired blood flow on the ipsilateral side, and that can lead to kind of like syncopal-like symptoms. So that was kind of on our differential as well here. Cervical radiculopathy as well, with the right arm symptoms with neck pain, any peripheral neuropathy, like ulnar and carpal tunnel, any brachial plexopathy, and then with malignancy, of course, just concerned about any new recurrence or spread or metastatic spread with perhaps a apex of the lung tumor, like a pancreas tumor, a compression sort of situation here. So we did gather more history from her, so apparently she had been following with a neurologist for a long time with the thoracic outlet syndrome, but seemed to have lost the follow-up. This was specifically at Northwell in New York, and she supposedly also had, I didn't include any prior past imaging in my slides, but I'm just going to let you guys know what we were able to see on the medical record here. So she had a prior CT of the larynx back in 2023, just to look for any recurrence of her thyroid disease, thyroid cancer. So there was no recurrence at that time, no recurrence in the thyroid bed. Interestingly, she had an incidental right cervical rib, so that also was a huge relevant imaging finding in her presentation. So that was evident back on a prior image in 2023. She also had a CT of her thyroid in May of 2024, and there was, again, interval right thyroidectomy bed without evidence of recurrent disease at that time. So the way we kind of approached the conversation with her, we wanted to make sure that she understood what a more emergent red flags would look like, getting very concerned about her vision impairments. And so we asked her if she could send us any prior imaging and workup studies she had from her prior neurologist from Northwell, and let her know that if she had progressive symptoms, like even worsening neurologic weakness, worsening of visual impairments, to go to urgent care or the local emergency room, avoiding any overhead movements as much as she could, given that was what made her symptoms worse, kind of trying to position herself in a more comfortable position at night, but still staying active as much as she could, and preventing further deconditioning as she could, just kind of ergonomic positions when using her computer at work or phone. And then we ordered a MRI of the C-spine just to see if there was any cord involvement, potentially like a myelopathy picture perhaps, or assessing for cervical radiculopathy, maybe picking up on any associated muscle hypertrophy like scalene muscle hypertrophy, or other vascular abnormalities going on. We also ordered a dynamic venous and arterial Doppler ultrasound, just to rule out any vascular thoracic outlet syndrome or other proximal vessel abnormalities. And then we were going to consider a referral to a vascular surgery just for her to seek a consultation about maybe resection of that cervical rib that we knew that she had that may be a contributor in this case as well. Yeah, to this date, I don't think she's underwent the vascular ultrasounds yet. So I don't, you know, she hasn't followed up in our clinic since this visit. So, you know, I can't really report how the symptoms have progressed since this initial visit, but definitely an interesting study for us to see. And then, so some of the learning points, I didn't mention the exam tests that were positive for her. So the Adsense and the Wright's test. So with the Adsense, you're abducting the symptomatic arm about 30 degrees and extending it maximally in a seated position. And then you palpate the radial wrist, radial pulse. And then you kind of ask the patient to take a deep breath, hold it. And they're turning their head toward that symptomatic arm or shoulder. And, you know, you can have a positive test if the radial pulse is, you know, decreased or disappears or if their symptoms that they're reporting are reproduced. In her case, it was more so like the paresthesia and pain-like symptoms and more so than the radial pulse disappearing. And then the Wright's test kind of similar, looking for a decrease in your radial pulse or reproduction of those paresthesia-like symptoms. Just putting your arm in a different position for this one, where you're going into abduction, external rotation to 90 degrees. And then, you know, the arm is then held in that position for about a minute. And again, testing that radial pulse, see if it disappears and then put the arm into hyperabduction after that and looking for any similar symptoms from the patient's report. Another one that you may have heard of is the Roux's test. That one, you're having the shoulder abducted at 90 and externally rotated at 90 as well. And then kind of asking the patients to slowly open and close their hands. So that's another test to assess for any neurogenic or like vascular thoracic outlet syndrome. And then, you know, just have like a diagram here about the thoracic outlet, some anatomy. Always nice to refresh some anatomy here. So you have your anterior scalene muscle that's anterior, the middle scalene muscle that's posterior, and then your first rib that's inferior, you know, kind of surrounding the neurovascular bundle, your brachial plexus and subclavian artery, subclavian vein, you have your pec minor there. So just a brief overview of these physical exam tests. Yeah, and then I was curious, you know, what is the prevalence and incidence of these sorts of things? So interestingly, I think having a cervical rib, it's about 0.5 to 1% of the population. And then for neurogenic thoracic outlet syndrome, you know, it's reported to be up to 8% of patients, usually in a younger population. And in this patient, she was in her 50s, but usually between 20 and 40. Again, the paresthesias, the pain, the fatigue in the upper limbs. And sometimes you can have like autonomic dysfunction, dizziness, headaches. And then the subclavian steel syndrome is more patients who may have like atherosclerotic disease. And they may be men between age 50 to 60, history of smoking. This prevalence is about 0.6 to 6.4%. So the idea is you have a stenosis of the subclavian artery, and that's resulting in decreased blood flow. And therefore there can be some compensatory retrograde blood flow from the vertebral artery to the subclavian artery. And that can lead to kind of cerebral ischemia because of that retrograde flow of blood. And they can have symptoms of dizziness, double vision, dysarthria even, and limb ischemia symptoms. So another diagnosis to keep in mind when you see this sort of presentation in the right context with, I think the comorbid conditions. Yeah, and that's kind of briefly what I have. So if anyone has any kind of comments or want to share any anecdotes about similar types of patients they've seen, definitely open to hearing about it and how you've treated them in the past. Nice presentation, Sammy. A couple of quick questions. One was, did you guys ever wind up getting the records? Cause it sounds like this person had seen some specialists in the past for this, but did they ever actually like do anything about it or was she ever like formally diagnosed? Yeah, I think she had a formal diagnosis. We did not get the records. To my knowledge, we got her chart and I didn't see any follow-up visit with our physiatrist. I believe that she had even a consultation with someone in the past about resection of that cervical rib. And maybe there was some discussion about her needing like a breast reduction surgery or something. I'm not sure the context, but she did mention something along those lines of prior conversations with surgery. So I think, yeah, it just amazed me how long she had been living with these sorts of symptoms and really not, I guess, committing to a certain treatment, I guess, like in the context of all this. Thanks for that presentation. I'm curious. So did she have these symptoms before the thyroid surgery or only, or like she had it for a little bit because she had a diagnosis, it was fine, asymptomatic, and then it got worse after the thyroid surgery? Yeah, yeah. It sounds like she has had these sort of symptoms for more than 20 years. And then the thyroidectomy was in 2021. I guess maybe there was worsening or more frequent symptoms after that. But it sounds like the symptoms predated the thyroidectomy. So questions I often get asked is why? Why did it get worse after thyroidectomy? Did you get asked that or like how would you answer that question? Great question. I mean, we didn't, she didn't specifically ask us that question. It was, yeah, but I can imagine patients might be curious why. And yeah, I'm not even sure how to answer that one. Well, I cheated. I did a quick search on why, how you could potentially answer that question because maybe our patient population is very different. And so intraoperative positioning can potentially pull on the structures. If it's right after surgery, they might have a hematoma. They might have scar tissue or fibrosis. They might have altered mechanics. You mentioned getting an MRI to look at the scaly muscles. So maybe they're holding their shoulder and posture differently afterwards. So just some ideas. Doesn't seem like there's much literature connecting TOS to thyroidectomy, but yeah, just wanted to note for everyone. So sometimes patients ask why a lot of like, is it the, it's the surgery's fault or it's the cancer medication's fault? Like, can it be that leading to my current problem? Yeah, the positioning part makes sense, totally. Just don't know why it's lasting so many years after the surgery too though. But yeah, I think she was a fairly sedentary person. So there wasn't like any, I know you can have like, maybe there's a concern for like scaly muscle hypertrophy and people who are like heavy weightlifters or frequent like overhead pressers or like swimmers, for example, or sort of athletes doing a lot of those overhead movements. Yeah, I have seen it listed as a potential complication. I don't think it's super common, but it is listed as potential complication of thyroidectomy, but it's usually more for people that have like really big bulky thyroids that kind of tend to go posterior from like goiters or larger tumors, but. Dr. Bateman, I see your hand is up. Yeah, from a musculoskeletal standpoint, far more common to have these kinds of problems from orthopedic surgery, the neurologic surgery, and then more common in neurologic surgery or neurosurgery than general surgery. But I get these questions a lot because I do EMGs. So a couple comments, there's this thing called idiopathic brachial neuropathy. And we used to think, we just didn't know, right? Cause that's why it's idiopathic. But now some people think it's kind of an immune mediated process where the stress from surgery does it. So it's not like a mechanical compression from surgery, but it's like all of the chemical factors that you release when your body is attacked as it would be in a surgery can actually affect your nerves in a weird pattern that mimics brachial plexus. And it's kind of wild cause now on ultrasound, they're seeing these weird torsions of nerve that aren't even in places of compression. So this doesn't sound like this patient just cause she had a history. The other comment I would, is the seronegative rheumatoid arthritis. I see a ton of autoimmune disease and autoimmune disease can do weird neuropathies. Could be that, that can happen, both idiopathic brachial neuritis and autoimmune neuropathy can happen in the absence of local compression. It's people get really frustrated because the treatment is physical therapy. Some people will give steroids, some people will take steroids kind of depending on where you are on that line. I can tell you when I was in Boston, I saw a ton of patients post-rib resection that were not better. So obviously I'm very biased against TOS, but I think it gets a lot more complicated when you start adding in cancer and cancer treatments. And certainly you're gonna be a lot higher risk for head forward posture and all these other things, more likely scalene atrophy than hypertrophy. I bet more on surgical stress and autoimmune or some combination thereof. You could consider treating with a short burst of steroids. Most, I would say like people my age and older would, and maybe people my age and younger wouldn't, hotly debated, but therapy, therapy, therapy. Yeah. Thank you, Dr. Bamu. That's really interesting. I haven't seen a lot of those cases. Is it more of like a, for those like autoimmune ones, is it more of like a neuropraxia where it then just gets better or? Yeah, yeah, and it's usually distal. Like those are usually median or ulnar, and sometimes they can mimic a compression. Like the CI, now that I'm more towards the private than the academic, I see a lot of cubital tunnels that were released that shouldn't have been and are not better, and that's heartbreaking. The other thing everybody should know if you don't already is that the position of your elbow during electrodiagnostic studies is very important. So 30 degrees change in a position of your elbow during the ulnar nerve study is gonna completely change the study and mimic ulnar neuropathy when it's not even there. So figures don't lie, but liars can figure. Just, if you didn't do the EMG, I'd be very wary of an EMG report of ulnar compression neuropathy in a patient like this with a cancer history. That may not be what's going on. I would definitely second that as far as the quality of the myographers. For anybody that's going out into the world, especially you fellows, and if you're gonna be either starting programs or working in unfamiliar places, if you're not doing myography, you should figure out who your go-tos are as far as people you actually trust to do a good study, for sure. The other thing you can do is, my partner's family medicine, sports medicine. So she does a lot more ultrasound. She's also 10 years younger than me, right? So she does a lot more ultrasound. But, so sometimes we'll tag team a patient, and that's been really helpful in terms of understanding the diagnosis. Yeah, thank you. That is interesting. I have seen a handful of the thoracic outlet releases, and I would agree they tend to be, in my experience, not as helpful, and have often actually made things worse. But I also have a suspicion that a lot of those people are misdiagnosed. Like, I have one patient that just clearly has a radiation-induced brachial plexopathy and nobody wanted to believe it. And I told her, yeah, I think that's what you had, but she had already had the surgery and it made it worse. And I was like, I would have never suggested that in the first place. But yeah, I think some of it is the devil's in the details. I do think that the additional rib thing is pretty interesting. I would definitely agree with some more imaging on that. Sammy, I did want to ask, is there a reason why you guys went for the cervical spine as opposed to an MR of the plexus? Did you feel like maybe a plexus might have given you a little bit more views of a little bit lower down? Did that conversation ever happen or was that ever considered? Well, I think that was definitely considered. I think we were just so swayed, I guess, by her self-reported history and we're just kind of trying to get something that might happen quicker. Yeah, I think my attending kind of pushed for the C-spine more quickly. And then I think she's had more experience, of course, like seeing these sorts of cases. So she had a go-to person in mind to get like a dynamic vascular ultrasound study. And I think EMG and MRI brachial plexus was something we would do like in addition, like in the future, you know? So, but yeah, I think that's definitely a good and important diagnostic study to do as well. Another consideration, if you can get the records would be, you know, try to get the op report. I've gleaned a lot of useful information by actually going through the actual operative reports and seeing like what approaches they use, what they cut, those kinds of things. And sometimes you can actually learn a lot from what to anticipate from that. Yeah, that's a good point. Yeah, just looking exactly what was resected and sacrificed or moved around. And I think that can all, yeah, contribute to the clinical picture. Yeah. You know, another interesting thing I've just, I've done, usually not this type of population, but you did mention that she had some tenderness over the PECS areas. And, you know, I have seen people just get like intermittent kind of plexus symptoms that just kind of come and go secondary to just entrapment under like a really tight PEC minor. It's using the breast cancer population that I see and particularly people that have been radiated. But sometimes just kind of doing a little compression right there around like just below the coracoid will sometimes just reproduce their symptoms. And that's another thing that can sometimes be helpful. And I have actually Botox the PECS, particularly the PEC minor and had success doing that in the right patient. So I thought it was interesting that you mentioned that somebody had talked about like some kind of a breast reduction surgery, not your typical risk factor that I would think of, but. Yeah, I wish I knew more about, you know, what was that actual conversation like and whether that was in the setting of maybe that was contributing to the clinical picture or whether that was something, you know, the vascular surgeon was advocating for to make his sort of approach better. I'm not entirely sure like what, in what context that was suggested to her. Anecdotally, I've seen a lot more improvement from breast reduction than I have from rib resection. I mean, it's a very small number of cases. I'm talking over 20 years, but just my two cents. I have previously been called on to write letters to insurance for breast reduction, which have been wildly unsuccessful, but I anecdotally it seems to work better than rib resection in a female patient, of course. Anybody else have any other comments or questions on this case? Okay yeah same as an interesting case I think I'd be curious to see how this shakes out so keep us updated if she gets followed up and some of this testing comes back. I'd be really curious just to see kind of what shakes out and especially with some of those imaging studies I mean I think the bachelor study makes a lot of sense too so. Yeah thank you yeah definitely curious too I mean yeah just 20 more than 20 years it's you know really surprising that nothing has been kind of done at this point still. It's always tough to reconstruct things that all day when patients have had a lot of care elsewhere and you're trying to kind of pick up a lot of pieces without reinventing a wheel. Yeah okay so it's on the oh go ahead. Was there another case? I didn't want to you know kind of be taking all the time. That was going to be my segues it looks like Dr. Cheng in the chat has a case. Okay let me stop sharing here then. Yeah this is actually a case in development that I saw recently and you know Dr. Bymum when you think about it talking about immune-mediated neuropathy potentially and so this is a woman in her 50s she had breast cancer finished treatment and then one week after she finished her trastuzumab one week after stopping chemotherapy this was a month and a half ago she started having steady progressive weakness in both hands distally so distal forextremities and legs she had multiple falls within a week she stopped working in health care because she couldn't drive anymore she started using a walker completely she's marginally independent with ADLs completely dependent with IADLs it was all within a month and a half period of time um and so that's when I saw her for outpatient consult so her extremities were like three plus four minus strength and then she also had pretty slow rapid alternating movements a little bit of dysmetria no pain nothing else otherwise neurologically okay um and so I ended up directly admitting her to the other hospital um across Southern California where she was closer to and where we have a hospital and so they've been blasting her with steroids no significant improvement she just had her second day of IVIG with um maybe slight improvement her imaging her MRI brain didn't show anything remarkable it says focus of enhancement within the left caudate head and right thalamus that is non-specific and then a MRI spine showed some some neuroforaminal stenosis in the low lumbar and subtle t2 hypertensive cord signal ascending from the upper vertebral body of t10 to the conus without cord expansion or enhancement correlate for possible transverse myelitis they did a lumbar puncture uh with nothing significant so far and so that's where we're left at the neurologist is going to do a nerve study that was just done I'm not sure if we have the results yet um but just wanted to bring up this case because I have not seen I've seen ICI mediated neuromuscular issues and um any checkpoint inhibitor but she was never on any of these immune medications um immunotherapy so just curious if anyone's seen something like this or have any comments on this case I can definitely tell you my first thought would have been AIDP, so I think they were, you're right to admit her. I'm a little surprised they tried to send her outpatient first, but sometimes we do get these. Yeah, I would have probably pushed for an inpatient EMG as well, but it sounds like they've already kind of gone down that road. She's already into IVIG, so you can see kind of how it shakes out. I think the fact that she's had it that long is not the greatest sign, because that means like, you know, I find that in those cases, like the earlier people get to IVIG, usually the less, the better things are happening afterwards, so could be that she's just catching up, but do you know what, did she just get her septum, or? It was a week after stopping it. A week after stopping it, and was that the only treatment she had, or did she get like TCHP or something like that, or? Yeah, she had skin-sparing mastectomy, a reconstruction, single lymph nobiopsy, never had radiation, so very standard early breast cancer care, and so that's why it was kind of weird to me. Also, she had, because she has fallen so many times, she already went to the ED, and I was like, just so did the neurology get consulted? Did they do anything? I was like, nope, and I was like, what? I don't, this is outside, outside hospital, not a cancer hospital, so I was like, this doesn't sit well with me, and your spine MRI is at another institution in a couple weeks, your neurology consultation is at another, yet another institution in maybe a month. Perineoplastic workup, LP, yes, Hannah Hunter, Dr. Hunter, they did an LP, it didn't look like there's anything, any findings there. I think perineoplastic workup takes a while to result. Yeah. Isn't it always like that? Do you know if they ordered antibodies? I believe they did, because I talked to the neurologist, and we talked about all this workup that we've mentioned, and I was trying to ask, like, do I draw the lab? I haven't done, I haven't ordered this before, and even if I get the results, like, do we really want to wait weeks or months, or I'm not going to give IVIG myself, so that's when I ended up reaching out to the neurologist at the other campus to see if they could help. Yeah, I would say the what you've done so far makes sense. I don't know if there's anything else I would. Add at this point, especially if she's kind of just in the middle of IBG, I'd kind of see how that goes and sounds like she'd probably benefit from like an inpatient rehab stay. That's exactly what I was thinking, actually, because I don't work at that campus. I was thinking of this is if she might benefit from inpatient rehab and we try to direct it to the colleagues that I know. I don't even though I can't formally consult, which is hopefully it's not taken badly. I'm I'm sure advocating people wouldn't hold that against you, but I mean, it sounds pretty straightforward, except unfortunately, the standard of care is not the standard everywhere. Yeah. Yeah. And this is challenging just because of the many different institutions involved in not having things in house and feeling like I'm micromanaging people and pushing on colleges to admit an institution where they're not at or at a campus they're not at. I think you're doing the right thing. I found that, you know. Polite, but firm emails can go a long way, and usually at the back end, people are grateful for the attention to detail and they wind up trusting you more on the back end, especially when you're going the extra mile like you are so. Yeah, I just call them. It's not in these cases, but I have seen some more of this type of thing, but really more of just really crazy, like ADP and like weird peripheral nervy stuff with. Some of the parties are doing it, particularly one called Carvicti, so I never really paid much attention to the brand of Carti before recently, but the Carvicti one has been causing a lot of really weird stuff in particular. And so some that's like irreversible, like nothing's working. So a completely different type of setup. But I'd put that on people's radar if you see people that are in the hematologic malignancy populations. I can tell you what I would do, but we can, I don't want to jump too far past Dr. Chang's case in case anything else, anybody had other questions or comments. I don't have too much to offer Evelyn for tongue spasms, but I thought I've heard Botox. I've not done it myself for tongue spasms. Yeah, I was going to say Evelyn for if they've been radiated, that can often be myokymia and I've just seen it like this obvious circulation, people that have myokymia all throughout the face, the platysma, the neck, um, if they'll let you Botox it, it's pretty easy to Botox, especially if you go under. So you can either like pull their tongue out and just stick a needle in there, but, or you can just go through the bottom of the chin. Yeah, I was seeing literature for the Botox and that you can go under the chin. These ones are only occurring like five to 10 times a day and not with any particular talking room activity. So I can certainly bring it up, but I don't know if they'd want to do Botox for, I was curious if there was other things you guys have tried besides that, but, appreciate it. Five to 10 times per day, I've offered some Botox, but so far my patients, more for platysma and so far they're like, no, thank you. We'll just avoid activating it. I guess I'm also concerned, like, will it affect speech and how much weakness, like my experience is so minimal with tongue Botox that I don't know the extent and dosing and all that stuff. I don't know, but maybe Christina Klankula, so I would ask her, maybe she would know. Yeah. Yeah. If you don't get a good answer, you could, if the patient down for you, try a low dose, but it's a thing. If you think it's my economy, I always remind people that my economy is a nerve problem, not a muscle problem, although you've seen the effect in the muscles. So it can respond to neuropathic agents, unlike other types of like, you know, dystonia and stuff like that. So you could consider even just trying like a gabapentin or something. Okay. Thank you. But also sometimes just reassurance goes a long way to just telling people, like, I think there's a downstream effect of your treatment, but it's not dangerous or doesn't mean your cancer is coming back or something. And then if, if they, if they don't really bother by it enough to like take medicine or, you know, stick a needle in it, then I would just keep an eye on it. I will say, I don't think I've seen it isolated that I can think of. Usually it's in conjunction. They have like, you know, spasm elsewhere too, like the neck or the face, usually the face. Yeah, usually I think there's some spasms of like the neck as well, but I've seen a couple of patients who've now mentioned with head and neck history and radiation and all this, probably some neck dissection as well with the tongue spasms. The other thing, when they describe a tongue spasm, are they talking about the tongue itself or does it feel like, like a locking sensation under the jaw? One of them showed me a picture and it was literally a tongue deviation to one side. Interesting. Yeah, I mean, that sounds like I've seen the digastric be involved too, but. Another thought, Evelyn, is maybe it's not related to the head and neck cancer at all. Yeah, I've looked into some of those cases too. There's something about like chewing gum or something that like reducing stress and anxiety too that is helpful in those like focal dystonia sort of cases that I was reading. Did you consult neurology yet or anything like that? Not, I'll have to look back for those two patients if they've already seen neurology. I think they had might have now gotten a stroke evaluation to rule out anything with the tongue deviation at one point. I don't disagree if you have like a movement disorder specialist in the neuro department. Would be reasonable to get their opinion on it too, but. Evelyn, is this new or has this been like ongoing since treatment? Because I think one thing, like I've had patients who actually present with recurrence with like hypoglossal nerve involvement. So if it's new, I would say work up. I've had a patient who literally came in with tongue deviation. They had like a new lesion. They radiated it and now it's tongue straight. So I think making sure there's no underlying reason, especially if it's a new symptoms in the morning. Yeah, this one that I'm seeing tomorrow, it developed after her treatments and I'll double check tomorrow, but yeah, it's good to rule out lesions and neurologic deficits and all the above. Yeah. Secondly, what Dr. Hunter said, I've also seen osteonecrosis of the jaw present with some kind of weird worsening or new symptoms and it just wants to be in the jaw. So you know, the thing to think about, does anyone else have a case? I feel like I have so many weird cases. Okay. Maybe this one's a shorter one. This guy looks, seems like he's not on cancer treatment anymore, he had esophageal cancer. Seems like classic rotator cuff syndrome on exam and did a subacromial injection, went to PT like five months, does the home exercise program, not getting better, super severe pain, taking opiates like candy, palliative care is not happy with him or taking more opiates than needed. He is a alcohol kind of substance use history. Also, he tried sharp wave therapy once, didn't see any benefit, had acute cervical reticulitis before an epidural help, but this is totally different and he blames the Keytruda for the shoulder pain. And then he has new onset vitiligo. And so we refer to rheumatology and social work for psychosocial assessment and trying to have someone else take care of his opiates because he's not listening or following through on our recommendations. I was just wondering if anyone's seen something like this before. I've seen some pretty refractory inflammatory arthralgias from Keytruda, but it's usually not that kind of oligo to like one joint when it's that severe. I find it tends to be a little more diffuse. I would also be suspicious of, if you did a subacromial injection, I mean, when that lidocaine is working, it should take the pain away even for like an hour. Okay. It did, but then he denied it later. So there's a psychosocial component that's really confusing also. So he was like immediately really happy. And later on, it's like, oh, you hit a nerve. You made it worse. You went to a family doctor and got several injections in the same place, but can't tell me where, and they don't have records. And they both made it worse. But yeah, it's only one shoulder. And he got, oh, go ahead. I was just gonna say a big picture consideration with like the esophageal cancer, like is his intake and like nutritional status okay? I think sometimes like it can be challenging for patients to build muscle with exercises, even like rotator cuff, typical PT, and so if he's getting stronger and he's still having pain, I think that's one thing. If he's not making functional improvements with like targeting that rotator cuff, like looking for underlying like metabolic reasons why like nutrition intake or absorption are things to consider. In addition to all this psychosocial stuff, but it sounds challenging. He did say that, so no evidence of recurring cancer. He's getting regular checkups with his oncologist. He's doing the home exercise program in the gym. He's like, look, I can raise my hand more. It still hurts the same, but he can raise it higher. He had his last prednisone 20 milligrams, I think for a few weeks, didn't help anything. Anything on ultrasound or imaging? He does have rotator cuff pathology on MRI, actually. So it's all consistent with the classic rotator cuff syndrome. Do you know what he's actually did in PT and what he's doing for his home program? I forget exactly, but I remember asking and thinking that it sounded right. And it's a PT location that has a good reputation also. He does have infraspinatus tendinosis, long hip biceps tendon tendinosis, but it's like classic near sign, Hawkins sign, lift off sign, positive, nothing else positive. Just classic rotator cuff syndrome, not responding to treatment. He also tells me mixed histories. And then the palliative team is like, oh, he says he's in severe, horrible pain, but he went fishing and all this high level activity recently. So there's some of that going on too. But I think what we were wondering with the new onset vitiligo is, is there something real here or rheumatologic or autoimmune happening here with the new onset vitiligo? And is there something besides he might want opiates? Is there something medical that is actually going on here? I think the fact that you gave him a bunch of steroids and it didn't help probably makes a rheumatologic issue pretty unlikely. Yeah. sometimes also just having a frank conversation about, we don't really treat rotator cuff issues with a whole bunch of opiates. And once you've rolled out, like it's a cancer problem, you know, start being open and honest, but with like a clear like ween plan. Yeah, I left that to the palliative care team. So thankfully I didn't have to do that. But yeah, that was definitely a conversation that's been had. I was just wondering if there's something I'm missing here or some, if anyone's seen something like this or if we really could chalk it up to psychosocial things. Or opioid induced hyperalgesia. So, you know, we see this all the time in the back pain population. And I used to see it, I had a patient with like testicular cancer and he had a lumbar infarct and it was so heartbreaking and palliative care pounded him with opioids and then he lived, right? And so he had to get off of those and it's so hard and they feed back and increase your pain and decrease your pain tolerance. They also stop up your bowels. They also decrease your hormones. Like they do a lot of crap that cancer treatment does as well. And that's well documented. It wasn't well known 10 and 20 years ago but that's well documented now. So that's usually my approach with patients is these opioids are feeding back and giving you more pain. I would recommend you get off of them for that reason. If you're not on that train, it was nice to meet you, have a great life. I'm not very nice though. Yeah, so you've actually seen it because I've brought that up a few times with different providers and they're like not sure that that actually exists, the opioid induced hyperalgesia. That absolutely exists. And I think a lot of, so everybody's on the hook now for payments and where it's getting more attention is anesthesia because anesthesiology as well as surgery are kind of partnering together to improve outcomes. So like prehab is my jam, right? But like ERAS and all that other stuff, pain is really important. And the less opioids people get, often the faster they recover and the quicker they're out of the hospital and the better they do. So I think there's more attention around it now and there's a lot, it's a lot easier to back up what you're saying with literature now than it used to be, but it's an exceedingly hard fight and I'm not saying it's easy. I'm just saying, I'm mean. I've had patients die on opioids that were not prescribed by me, young patients, and it's terrible and horrible and very bad to watch. So, you know, think I'm mean, say nasty things about me on Yelp, but I'm doing my best to protect you from yourself. Thank you, John. I guess keep fighting the good fight applies to this as well. None of it's easy, but you're doing the right thing. Thank you, thank you. Evelyn, our right arm thing is also treating OA patients with low dose radiation. And I've had one, not many, I haven't had many patients share it, but I've had one patient say like within five days, pain is gone. The other thing is if you look at musculoskeletal studies, they take asymptomatic patients, MRI them, and they have partial cuff tears. So as long as he doesn't have a full thickness tear, if he has a partial cuff tear, you know, that shouldn't be causing this much pain. Yeah, there definitely is a discrepancy here. I think there's sometimes a little bit more of a tendency to distrust yourself. When you're early on in your career too, you know, I've definitely dealt with that where you're like, okay, what am I missing? What am I missing? When, you know, you're also describing a picture that also makes a lot of sense. And I think it's always important and good to question your diagnosis and think down those routes, but sometimes it's just, your gut might be right. And it's so much harder in the presence of cancer than in the absent. Like if you're just looking at a regular musculoskeletal patient adding cancer, 10 times harder, right? Yeah, especially, you know, you have a different skill set than a lot of the other people there. So you know how to evaluate a shoulder and it's all pointing towards that thing. You know, if it was a little more vague, you know, you can get a little bit outside the box. I have seen some weird stuff with cancer, like people that have shoulder pain that winds up being like cardiac or, you know, esophageal probably shouldn't refer to the shoulder, but there's some weird stuff as far as some like actual, like visceral type pain syndromes, or, you know, I've seen people present with like kind of weird, but sounding like, you know, muscle spasms, stuff that even responded to trigger points and wound up having like esophageal candidiasis and stuff like that. So sometimes it doesn't actually boil down to like an MSK or neuromuscular type issue, but otherwise I go back to say it sounds like what you've described kind of makes sense. We are one after, so I want to respect everybody's time. Really interesting cases in discussion, everyone. Like I said, this is always valuable to get the feedback of pretty much everybody in the community that's seeing these patients because we're still a small group. And this consensus kind of opinion and kind of sounding board stuff is really valuable. So thank you all for your participation. And let us know if you have any other case. If anything comes up in any of your practices and you want it presented here, always feel free to reach out to us. Our email is always just cancerrehabtumorboard at gmail.com. I can put that in the chat.

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