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Old 10-06-2003, 01:42 AM   #1
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Post Help with dysphagia / throat discomfort...

I have been having trouble with my throat since mid-July and am looking for folks with similar symptoms and experiences.

For background, I am 42yrs old, M, former smoker (quit 8+ yrs ago). I rarely drink, and when I do, only wine. I was treated for depression two years ago (Effexor and Clonazepam) but got weaned off the Effexor because it made me narcoleptic and I gained 40 pounds, which I have since taken off (back to 173lbs, 6' tall). I have stayed on 1.5 mg Clonazepam a day, 1 in the AM for stress and .5 in the evening to help me sleep.

In mid-July I was eating a salad and got a chunk of lettuce caught in my lower right throat (above the esophagus as far as I could tell). I wasn't choking, it was just sitting there and no eating or drinking would move it. After ten minutes I thought about going to the doctor or ER, but I leaned over, coughed real hard and up it came.

After that, I had a continual sensation of there being something in my throat in that area. I saw an ENT who performed direct (transnasal fiber optic) and indirect (mirror) laryngoscopies and he saw nothing. I then saw a GI, who suggested a barium swallow, which I did. In between the two, my ENT considered reflux a possibility and put me on Prevacid (which I have been on for six weeks with no effect).

The barium swallow report came back with the following findings: no structural abnormalities (tumors, strictures, etc), but did note a) considerable reflux, b) small hiatal hernia and c) pharyngeal pooling of barium, presumably before entering the upper esophageal sphincter. I discussed these results over the phone with the GI who suggested I stay on the Prevacid for a while.

Well, it's been a while and nothing much has changed. Food occassionally gets caught in my lower right throat, and I can always wash it down with liquid or more eating. I have no pain of any kind, and no heartburn. I have no loss of appetite. My annual physical (all panels: blood, metabolic, lipid) came back normal last month.

The sensation is transient, but occurs more often than not. I have the sensation of there being something in my lower right throat. The best way I can describe it is that it feels muscular and spasmodic. Sometimes when I am talking, a sudden movement of what feels like a muscle in that area catches me by surprise and forces me to stop talking. Added to that, is a near constant feeling of tightness around my neck, maybe an inch or two below my Adams Apple. I am forever pressing on my neck and wiggling the cartilage there in an attempt to dislodge the sensation, but it does not.

I am planning on a follow up with the GI and thinking that further options include esophagoscopy, 24hr PH test and pressure test. To me, the barium findings suggest a motility disorder (my words), if stuff is just sitting in my pharynx before entering the esophagus - perhaps muscular coordination?

Now, all of this started the week my wife and I found out we were pregnant with twins. Naturally, anxiety and stress related dysphagia come to mind as possible diagnoses. I am already on Clonazepam, which works well for me, so I would have thought that would be taking care of any stress symptoms.

Is it possible for extrinsic muscles like those running up my neck to spasm or be so tight so as to affect intrinsic structures in swallowing, or cause a 'globus' sensation? I had some manual therapy done by a practitioner who noted very knotted muscles all around my neck area down into my chest. I haven't had enough of that therapy for it to have any effect yet.

I'm not overly worried as I've already had some tests, and things are not getting worse, but they are not really getting better either. I can swallow food OK, but I am getting exhausted from this annoying sensation, and this transient internal 'bulge' that seems to interfere with my talking from time to time (I have to talk a lot in my profession).

Any suggestions on an approach to the next discussion with my GI? Anyone with personal experience like this, outcomes, medications, etc?

Thanks.

 
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Old 10-06-2003, 10:51 AM   #2
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Hi there. Being a certified speech-language pathologist who has dealt with swallowing disorders, as well as a person who has experienced various digestive disorders (incl. GERD), I recommend that you request a referral to a speech-language pathologist (SLP) who performs videofluoroscopy. This test will be very similar to the upper GI, but with less barium per swallow. What the SLP looks for is pooling of material in the pharyx, and how effective specific techniques would be to clear it, and protect you from aspirating the material. Since you report residual material noted on the upper GI, a good SLP will also try different techniques to see what works to help you clear it. An SLP only looks at how liquids/solids move from the mouth through the pharynx to the upper esophageal sphincter, and the upper GI tends to focus on the upper esophageal sphincter to the stomach. I've had many referrals from GI docs when patients complained of swallowing difficulties and the upper GI was not significant.

So when you go to see the GI, see if s/he will refer you to an SLP for further swallow evaluation.

Good luck and keep us posted,
Katie G

 
Old 10-06-2003, 02:34 PM   #3
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Thanks for the recommendation. I did consider this after reading about it somewhere else on the Web. At the time, I mentioned it to my ENT (I think it's called a modified barium swallow?) and he looked at me like I was a martian, so I dropped it. I may take it up with the GI though, because as you say, I think a focused study of the pharyngeal motility might lead to some useful therapy.

 
Old 10-06-2003, 09:25 PM   #4
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Hi..it sounds to me like your thyroid is enlarged, this is what I have and have the same symptoms you do.

You can have a ultrasound done to find out.
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Old 10-06-2003, 10:47 PM   #5
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lovemythreeguys2002, thank you for your post.

It sounds certainly like it's worth investigating, but I would thought in my case that if there was extrinsic compression from an enlarged thyroid, it would have shown up on my barium x-ray? They are supposed to be quite good at outlining compressions as the barium traces the structures under investigation.

Also, were your symptoms intermittent or constant? Mine come and go - so if I had an enlarged/enlarging thyroid, then I'd guess I'd have a constant feeling.

 
Old 10-07-2003, 10:31 AM   #6
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Quote:
Originally posted by sir-tainly:
lovemythreeguys2002, thank you for your post.

It sounds certainly like it's worth investigating, but I would thought in my case that if there was extrinsic compression from an enlarged thyroid, it would have shown up on my barium x-ray? They are supposed to be quite good at outlining compressions as the barium traces the structures under investigation.

NOPE...I had a barrium swallow too and it came back normal.

Also, were your symptoms intermittent or constant? Mine come and go - so if I had an enlarged/enlarging thyroid, then I'd guess I'd have a constant feeling.
Comes and goes.....
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Old 10-07-2003, 11:51 AM   #7
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Was your barium swallow completely normal, or did it reveal pharyngeal pooling of the barium, or any reflux? It is the cause of the pooling that I will be looking for...

Thanks.

 
Old 10-07-2003, 01:20 PM   #8
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I was just told the results said "normal"...if something was found, I am sure they would have told me.
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Old 10-08-2003, 08:30 AM   #9
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Hi again sir-tainly. You're right - the videofluoroscopy is called a modified barium swallow or MBS for short. So sorry your ENT was not open to the suggestion - some ENTs feel that we SLPs are over-stepping our bounds when some of our disciplines overlap. Hopefully your GI is a better informed person.

Good luck and keep us posted,
Katie G

 
Old 10-08-2003, 12:55 PM   #10
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lovemythreeguys2002, I had a follow-up question regarding your thyroid dx...

Could you feel the enlargement, or was it discovered through other means (ultrasound, etc.)? Did you receive treatment for it, and did that resolve the other problems? Who decided to investigate for Thyroid problems - you, your ENT, or...?

Thanks again.

 
Old 10-08-2003, 05:16 PM   #11
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Quote:
Originally posted by sir-tainly:
lovemythreeguys2002, I had a follow-up question regarding your thyroid dx...

Could you feel the enlargement, or was it discovered through other means (ultrasound, etc.)? Did you receive treatment for it, and did that resolve the other problems? Who decided to investigate for Thyroid problems - you, your ENT, or...?

Thanks again.
When my endocrinologist dxed me with hypothyroidism, he said that my thyroid felt enlarged, I could not feel it myself with my hands.

Upon ultrasound, I was found to have nodules and now I have to have a scan....thyroid medication can shrink it sometimes, but some people just choose to have their thyroid removed and then take replacement thyroid medication.

Do you have ANY of these symptoms? These are hypothyroid symptoms....hyperthyroid can be opposite, feeling hot etc...

You feel tired, exhausted, and like you can't get enough sleep, or want to take daytime naps
* You feel depressed, down, or sad
* You feel cold when others do not, particularly in hands and feet
* You've gained weight inappropriately, or you are finding it difficult to lose weight, despite proper diet and exercise
* You're losing hair, particularly from the outer part of your eyebrow, or your hair is getting dry, or tangly
* Your nails are breaking and splitting and become brittle
* You have muscle and joint pains and aches, or you've been diagnosed with fibromyalgia
* You've been diagnosed as having chronic fatigue syndrome
* You have carpal tunnel syndrome or tendonitis in arms and legs
* You have swelling and puffiness in the eyes, face, arms or legs
* You have a low low sex drive
* You have heart palpitations or a diagnosis of mitral valve prolapse
* You're suffering from unexplained infertility, or have had recurrent miscarriages with no obvious explanation
* You have had a heart attack or have clogged arteries
* You have high cholesterol levels, particularly the type that is unresponsive to diet and medication
* You have a heavier than normal menstrual period, or your period is longer than it used to be, or comes more frequently
* You're going through menopause, and are having troublesome symptoms
* You have worsening allergies, itching, prickly hot skin, rashes, hives, urticaria, chronic yeast infections, oral fungus or thrush, or stomach and ab******l bloating
* You have anemia, or an excess of iron known as hemachromatosis
* You find it difficult to concentrate, your memory is not as good as it should be, you feel like your thinking is "slow"
* You are constipated, sometimes severely so
* You have a feeling of fullness, or an obvious swelling in your neck area
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Old 10-15-2003, 09:40 PM   #12
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Quote:
Originally posted by sir-tainly:
lovemythreeguys2002, thank you for your post.

It sounds certainly like it's worth investigating, but I would thought in my case that if there was extrinsic compression from an enlarged thyroid, it would have shown up on my barium x-ray? They are supposed to be quite good at outlining compressions as the barium traces the structures under investigation.

Also, were your symptoms intermittent or constant? Mine come and go - so if I had an enlarged/enlarging thyroid, then I'd guess I'd have a constant feeling.
Look up laryngopharyngeal reflux (LPR) and see if you can relate to the symptoms. If your doctor didn't see any inflamation when he did the larynscopy I'd go to another doctor cause my symptoms are exactly like yours and started just like yours (while eating). I went through the thyroid scenerio too. You should really look into LPR.

 
Old 10-15-2003, 10:32 PM   #13
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TAF, thanks for the post. It's bizarre timing, because just today I was doing some more research and came across some articles on LPR that sounded far more like what I was experiencing than anything else I had read or been told. Also, my GI has scheduled me for an upper endo next week so he will be looking at the whole thing and I will be mentioning to him the LPR theory.

I really do not like my ENT. Apart from the initial scoping and a comment about mild irritation he has pretty much given me the brush-off and finally told me that it wasn't his problem and since the Barium tests showed reflux, that my GI should take care of it. It's been really frustrating.

From what I have read, LPR often requires more aggressive anti-reflux therapy and for longer periods of time than typical GERD and esophageal symptoms. That could explain why once daily Prevacid for only seven weeks has done nothing.

What tests/findings did you have done to confirm LPR and what subsequent therapies?

 
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