The claimant is a 57-year-old male with a disability date of 6/6/2013 due to moderately differentiated

squamous cell carcinoma of the larynx [supraglottic, T3 N2] with post-op complications including fistula
formation; also noted is a history of hypertension, Hepatitis C [without hepatic coma], and spondylosis
[of unspecified site without myelopathy], none of which affects any disability-related issues. The tumor
was not work related; it was due to tobacco-use [plus, perhaps, alcoholism].

His occupation is a Materials Handler, providing basic repair and maintenance of equipment under
direct supervision; he performs general housekeeping functions as needed. He has to learn basic
functions of equipment and processed in the workshop. The job is considered heavy work lifting up to
100 pounds maximum with frequent lifting and carrying objects weighing 50 pounds or more. He is
required to use vision, color discrimination, peripheral vision, depth perception, and hearing. The job
requires 4 to 6 hours of standing, 1 to 4 hours of driving, and occasional sitting. The job may also include
exposure to chemicals, heat and humidity, cold, dampness, fumes and gases, height, noise, and
radiation. The job requires repetitive motions such as simple grasping, fine manipulation, pushing and
pulling, finger dexterity, and foot movement. It also requires bending, squatting, climbing, twisting, and
reaching.

He presented on 6/04/2013 due to cervical lymphadenopathy during the prior three months; he also
had progressive odynophagia, pain referred to the left ear, and 20 pound weight-loss. He was a 1-2
p.p.d. smoker [60-pack-year] and ingested excessive [moderate-to-heavy] alcohol. A CT scan
demonstrated a lobulated soft tissue mass involving the epiglottis and left aryepiglottic fold plus
necrotic left level 2-3 metastatic adenopathy. He had a laryngectomy, left neck dissection, and left
thyroid lobectomy; the primary had negative margins [4.3 cm] and 1/20 nodes was positive [3.5 cm],
while there was both lymphovascular and perineural invasion. Labs revealed anemia of chronic disease
[hemoglobin = 10.5 g/dL], hypocalcemia [thus, no ectopic-PTH], and compromised nutrition [magnesium
= 0.38 mmol/L]; other labs and chest radiograph were normal.

A post-op right-sided pharyngo-cutaneous fistula was cultured [multiple organisms but no MRSA] and
treated with IV antibiotics; he also received total parenteral nutrition (TPN). The drainage persisted, so
the plan was for it to be opened, drained, packed and repaired; specifically, he had dissection of the
carotid sheath, debridement, with resection of the pharyngeal and esophageal mucosal margins to
obtain fresh tissue. He also underwent advancement closure, pharyngocutaneous fistula with layered
closure of the neck measuring 14 cm and tracheoesophageal puncture for speech prosthesis.

Post-op complications included abnormal (nasogastric tube) NGT placement [extending to the right of
the midline and appearing to be curled along the medial right hemidiaphragm, with the tip well below
the level of the hemidiaphragm] and right tension hydropneumothorax [requiring placement of a
chest tube]; due to these ongoing management issues, he underwent a PEG. Thereafter, he developed
persistent free mediastinal air [with the interval development of posterior mediastinal air
communicating with the right pleural space concerning for esophageal injury, perforation, or fistula]; the
right middle and lower lobes collapsed [with debris in the right bronchus intermedius]. Follow-up neck-
CT detected a fluid collection that could have been a seroma vs. an abscess. Culture revealed Escherichia
coli [1+] and pseudomonas aeruginosa [rare]; nutrition was compromised, as evidenced by albumin =
2.2 g/dL; thus, he had bilateral fistula drainage surgery, plus closure of pharyngeal and esophageal
fistula, and pectoralis flap. The discharge summary stated he had developed leak from the esophagus
that led to empyema; he developed a leak from the initial closure, plus atresia of the mediastinum; this
had prompted the subsequent closure of the larger fistula in the pharynx with a pectoralis flap. Thus, he
used hydrocodone 10/325 mg one every 4-6 hours [as needed] due to pain [6 to 7 on a scale of 0-10].
Due to aphonia, he had placement of a speech prosthesis.

Medications included amlodipine besylate 5 mg tablet by mouth daily, lisinopril 2.5 mg 1 tablet by
mouth daily, meloxicam 7.5 mg 1 tablet daily, Protonix 40 mg 1 tablet daily [prophylaxis], promethazine
25 mg 1 tablet every 4 hours as needed for nausea, diazepam 10 mg 1 tablet every 6 to 8 hours as
needed for anxiety, hydrocodone and acetaminophen 10 mg/325 mg 1 tablet by mouth every 6 hours as
needed for pain, and ondansetron 8 mg 1 tablet by mouth at bed time as needed; he also was given
Silvadene topical 1 percent cream 1 unit as directed. He received adjuvant Chemo-Radiotherapy [weekly
Platinol]; the latter caused radiation dermatitis.

On 12/2/2013, he was seen in an Emergency Room due to diffuse pain; morphine was provided, but no
definitive [new] diagnosis was rendered.

On 1/18/2014, he completed a disability questionnaire, on which he noted he had experienced a stormy
course during the past -year to which had not yet adjusted; his whole life had changed. Dysphagia with
solids had caused fluctuating weight, although he had stopped smoking; he could not stand and walk for
long periods of time. Medications caused, inter alia, imbalance, and he was going to speech therapy to
learn how to talk again. He weighed 175 pounds and was 6 feet and 2 inches tall. He could drive only up
to his doctor's office which was about 25 miles away from his apartment. His regular activities included
cleaning for 1 to 2 hours three times a week, watching television for 2 to 3 hours every day, and
attending religious services and volunteer work for 2 and a half hours once a week. He did not usually go
for walks and did not have any other things to attend to with regard to his personal needs. He did not
also have a regular exercise program. He said his physician advised him not to return to work due to the
swelling around his neck, and he opined that he could not work again due to his condition and speech;
he felt his condition would not allow him to hold down a job like he was used to have.

On 3/10/2014, ENT follow-up found his lesions had healed; there was no sign of local recurrence;
elevated TSH [4.64 uIU/mL] suggested hypothyroidism.

On 3/21/2014, he was seen in an Emergency Room due to neck swelling; fentanyl was provided, but no
definitive [new] diagnosis was rendered.

On 3/27/2014, he underwent serial dilation of the esophagus with bougies.

On 4/15/2014, additional medications included Viagra and Lexapro

On 4/15/2014, ongoing symptoms of pain and weight loss [152 pounds] due to dysphagia were noted;
medications did not include thyroid-replacement. Follow-up CT-neck on 5/20/2014 showed noevidence
of local recurrent or residual disease.

On 5/21/2014, his weight had increased by 10 pounds [162 pounds]; he reported chronic production of
excess secretions emerging from his tracheostomy, with admixture of some blood after a great deal of
suction.

On 7/28/2014, Lance Oxford, M.D. indicated that he was disabled and needed assistance with feeding
and bathing.

On 9/18/2014, he reported peripheral venous insufficiency.

On 9/29/2014, Alfredo Garcia, MD reported he had severe chronic back pain due to osteoarthritis of the
spine; as a result, he could not lift, bend, or walk for more than one-half block. He had difficulty staying
alert to complete tasks because of his chronic pain medication. He was unable to complete his activities
of daily living. He could not return to work at this time [even were accommodations made] because his
condition was chronic, would not improve, and worsened over time. He could never return to work with
or without restrictions.

On 9/30/2014, Eric Nadler, MD reported he was completely medically disabled and unable to work; he
cited multiple problems with his tracheostomy site that caused dyspnea and exertional limits. He had
copious secretions that prevented him from ambulating or walking great distances without having
significant shortness of breath. He was severely disabled and would remain so indefinitely.

On 10/10/2014, Lawrence Weprin, MD reported he had had tracheal stenosis that caused dyspnea;
strenuous activity [lifting over 5 pounds, bending excessively, or walking for more than one half block]
could cause exacerbation of chronic pain. He reported the patient had difficulty staying awake and alert
and was easily fatigued. He stated that he could take care of himself, complete daily hygiene, and
perform chores of daily living. He could not return to work at this time [even were accommodations
made] because his condition was chronic and worsened over time.