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Have vocal cord motion disorder and gastroporesis. Is this viral related?

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Internal Medicine Specialist
Practicing since : 1996
Answered : 961 Questions
I have had trouble swallowing since December 2011. I found that I have vocal cord motion disorder and gastroporesis but my mouth feels like its burning, I get sores on my tongue if I eat something sugary, I have lines on the insides of my cheeks. I feel as though my palate and back of it is stiff and can't get a a good swallow and not enough saliva, although an oral surgeon said that my saliva was producing enough. I think that it just isn't working correctly for some reason. I feel that I get alot of inflammation and feel there is pressure in my head and temples. I have had several blood tests and no diseases. The only thing that came up a little high, but dr's don't seem to worry, is my thyroid stimulating hormone and epstein barr titers for a past infection. I have been given systemic antifungal meds for 2 weeks in February and it seemed to help, although dr's are telling me it was a placebo effect. I do feel like my mouth is not pushing the food back when it get's to the palate stage, which makes me believe that there is an infection in my palate or something just not working right. What tests do you think I need? I've had manometry testing, barium swallow (which I think I need to have done again), gastric emptying scan which found the gastropresis, 2 endoscopy, and larynscopy where they found some bumps in the nasal passage, that looked like allergies. In all my studies they found mid inflammation and different points in time. Is this something viral that just needs to take it's course? I get really anxious when I cannot eat correctly. I feel like first thing in the morning I can somewhat swalllow but it just gets tougher and tougher, so I don't know if it is inflammation, or an infection with inflammation. The dr did KOH's (swabs) of my mouth and did not come back with signs of yeast or fungus after about a week.
Posted Tue, 2 Oct 2012 in Infections
Answered by Dr. Prasad Akole 10 hours later
Dear friend,

A well placed query indeed!

I can see that you took lot of tests. It would be better if you can load all the results here, so that I can read the exact diagnoses. You have a feature to upload the reports / image by yourself at the right side of the query page, please utilize that so that I can answer your queries better.

The pharyngeal and vocal cord weakness can occur due to many reasons.

One thing to my mind not evaluated here is myasthenia or like neuromuscular disorders. Was it considered? Was an MRI brain done? To look for lower cranial nerves affection?

Does the swallowing difficulty get worse as the day progresses? Is it better in the mornings?
Can you swallow solids better or liquids?
Did you get fever, vomiting?
Do you have eye muscle weakness, double vision, lid weakness etc.?
Do you cough when trying to swallow?

Is diabetes ruled out? How high is TSH?

Dear, such disorders require meticulous testing and complex procedures.
I should be able to guide you better if you post all the details of the tests, doctors' opinions etc. here.

I do not strongly feel it is inflammation/ infection as the root problem. It could be a neuro-muscular disorder and secondary infections etc.

I would appreciate and gladly help once you post greater details.
Take care and keep me posted on the progress.
Good luck.
Above answer was peer-reviewed by
Follow-up: Have vocal cord motion disorder and gastroporesis. Is this viral related? 5 hours later
Brain MRI normal, blood tests for mythenas Gravis negative. Neuro is setting up emg, muscle kinase testing. Will this be necessary even though I already had the brain MRI and mythenis testing. I will send my paperwork when I have my computer fixed later
To answer your questions, morning I have eye muscle weakness, like I've been squinting all night. Caffeine seems to trigger my pressure feeling in the head. My last tsh was a little high, dr wanted my primary to retest. Mouth feels very dry, no vomiting, sometimes feel nauseous in morning, but have had that for a while. No diabetes, weakness feels to get worse toward end of day. I have to be careful what I eat as it creates phlegm and makes it difficult to swallow even more.
Also I noticed this morning the line in my mouth goes all the way around to the front of my teeth, and has just came back.
Answered by Dr. Prasad Akole 6 hours later
Thanks for writing back.
I would wait more for your test results done earlier.

A normal MRI rules out structural reasons in the brain. Also, there is no diabetes, no fungal growth in mouth...

Though blood tests for myasthenia are negative, we still cant rule out myasthenia. Surely, the plan for EMG/NCV and CPK (muscle kinases) is the next appropriate step. I would also suggest edrophonium or neostigmine test to look for bulbar myasthenia.(under medical supervision)

Next, we should be looking at rarer muscular disorders like Eaton-Lambert syndrome, myositis, thyroid myopathy etc.
I think your neurologist will be the best person to confirm/ rule out all these. You should do a full thyroid panel (freeT4, free T3, ultrasensitive TSH). A CT thorax is also needed sometimes.
This being a complex diagnosis, you may also try a big academic/ university where a proper workup for the rarer disorders can also be done.
Post the other tests and your progress and I would revert back. Also if possible, post a close photo of your face/ neck as attachment on the webpage. Sometimes facial features help diagnosis.
Thanks for your persistence.
Here patience will pay.!!:)
Good luck
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Follow-up: Have vocal cord motion disorder and gastroporesis. Is this viral related? 2 hours later
Please see my attached reports. My most recent freeT4, free T3 were normal. I noticed that during times where I'm working hard around the house, I feel ok, but when at rest like right now, I feel the symptoms almost in my upper jaw or temples the issue swallowing. I almost feel a little shaky or tingling in my fingers. It's not really bad but it's noticeable. I am working with a XXXXXXX University ENT and Neurologist because it is closest to me.
I also wanted to add this, I started talking to a different doctor and want to make sure you have all of the information as I want to just speak to one doctor.

I have white lines on both sides of my inner cheeks, my mouth feels swollen and painful, and have trouble swallowing. It feels like I am having inflammation and pressure in head and from nose to mouth.
Asked by Me , 1 day ago

Doctor's reply to your question above...
HiThanks for the queryThe white lines on both the sides of the buccal mucosa are due to the teeth bite. This is the junction where the teeth of the both upper and lower jaw XXXXXXX and this part of the buccal mucosa usually gets trapped in between the jaws while chewing the food. It is a harmless condition and disappears slowly when the irritation passes off.Regarding the painful swelling in the oral cavity, it could be mucositis or inflammation of the buccal mucosa secondary to vitamin deficiency or allergy to some food/medicines. This will require a thorough examination of the oral cavity and throat as well as blood investigations to rule out anemia.If you can mail me a photograph of the oral cavity, I will be able to help you in a better way. For the time being you can try the following measures which will give you some relief:1. Drink plenty of warm water; avoid hot/cold food and beverages.2. Avoid fizzy drinks, alcohol and smoking if any.3. Try taking mild anti-inflammatory medicines such as diclofenac or paracetamol for the pain relief and multivitamins for increasing the body immunity.4. Also, you can try taking short course of oral steroids such as prednisolone for a quick relief.Hope I have answered your query; I will be available for the follow-up queries.RegardsDr. XXXXXXX XXXXXXX N.ENT and Head & Neck Surgeon
Replied by Dr. XXXXXXX XXXXXXX , 23 hours ago

Disclaimer: The Expert's advice is provided for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, as a complete assessment of an individual has not taken place. Please consult your nearest physician before acting on it. The advice is not valid for medico-legal purposes also.

Did I upload the pictures correctly? Also, this happens every time I eat and my vitamin intake seems to be good, I have had my b12, folic acid, iron, vitamin d checked recently and all in normal levels. I almost feel as if my jaw sounds like its craking when I open an close it. Again, I do have the vocal cord motion disorder and gastroporesis and have had unusual eye symptoms since January where I'm senstive to light and see an abundance of new floaters.
Asked by Me , 23 hours ago

Also, what is the best CT testing to show the mouth and jaw? I will be having a sinus and neck cat scan. Can this show irregularities in the mouth/ears as well? I am also feeling fullness in my ears and the clicking.
Asked by Me , 22 hours ago

Doctor's reply to your question above...
HiThanks for writing backYes, I do have received the images and I have examined it thoroughly. You seem to be having mucositis (inflammation of the mucosa) over the soft palate which could be secondary to the pharyngeal infection. If this is recurrent, then further evaluation has to be done to look for any chronic infection in the sinuses/throat and acid reflux disease. The crackling sound could be either due to opening and closing of the Eustachian tube following sinus inflammation or temporomandibular joint dysfunction. In either of these conditions there can be noise in the ear during jaw movements and yawning as well as fullness in the ear.CT scan of the paranasal sinuses will rule out any sinus pathology, it can also show any irregularities in the mouth. But for the ears, a different position has to be adapted and finer cuts are required; it is a high resolution CT scan of the temporal bone.If you can revert back to me after the CT scan, I will be able to come to a conclusion and advice you accordingly. Meanwhile, you can follow the instructions as I mentioned in my previous response.I wish you good health.Also, my doctor ordered an ultrasound of my thyroid.
Answered by Dr. Prasad Akole 17 hours later
Dear friend,

Sorry for the delay as I had obligatory ICU duty in the morning.

I fully remember to address to your problem.

Good, information posted shows normal thyroid profile, normal vitamin levels, and a colleague's impression of teeth bite and oral inflammation.
Great, all these infections, sinusitis etc. look secondary.

I would be interested in EMG/ NCV studies and muscle kinase levels.

Thyroid USG would be likely normal.

If you are getting a CT scan PNS (Paranasal sinuses) and neck, please request them to do a HRCT (High Resolution CT scan) thorax in the same sequence , so that thoracic (chest) structures get evaluated including a look for thymoma – a tumour associated with myasthenia.

It is comforting to know that you are being cared for at a university hospital.
You are on the right track.
And would guide you, after you post your scan and other reports.

I have seen the images that you had uploaded earlier. They show aphthous ulcerations and stomatitis.

Thanks for the interaction.
Above answer was peer-reviewed by
Follow-up: Have vocal cord motion disorder and gastroporesis. Is this viral related? 1 hour later
How can I request that when my doctor already worked up my neck ct scan? Also, we thought that the mouth stomatitis was because if thrush and I had two swabs done and they came back negative however the systemic antifungal ketakaze that the rheumatologist gave me seemed to work and my symptoms came back. Also my dentist noticed that I grind my teeth, could any of this be causin tmj?
Also, do I have to be Concerned with the mouth issues? I've had them for sometime and they seem to have gotten worse, ESP if I eat something really cold or sugary, but it also feels like my mouth is fryer than normal.
Answered by Dr. Prasad Akole 13 minutes later
Yes, since TMJ is controlled by muscles, any muscular weakness/ imbalance can cause TMJ to malfunction and cause occlusion line bite and ulceration. Teeth grinding could be contributing to this.

If the CT scan has not been done yet, of course you can ask them to scan lower down the chest in the same setting. Please discuss this with your physician. If this is not possible, we can thing about it only at a later stage once we have the results of other tests.
As for the mouth condition, you can use locally applied local analgesic+coating gels ( such as that containing Choline Salicylate and Benzalkonium Chloride) which should be available at a local pharmacy.
Let me know if I can address any more concerns.
Above answer was peer-reviewed by
Follow-up: Have vocal cord motion disorder and gastroporesis. Is this viral related? 2 hours later
The only other thing that I did not mention is that I had eye symptoms at the same time this all started, sensitivity to light, I have had several eye exams and a test looking at the optic nerve and they were all normal, except for some inflammation and dryness, I was producing about 1/2 the tear film than usual, I have been taking fish oil for about 4 months and it's almost back to normal, but not quite there yet. Could this all be related to my other symptoms? In the beginning I felt as if I could not focus and felt almost dizzy. That went away but have the light sensitivity which my opthamologist said this will not go away, however I feel it has improved somewhat. Also, in the beginning I would have bad after images. I still have it but it's not as bad.
also, sorry one more question, I thought in my paperwork i had the muscle kinase testing, is it the same thing? I think it was called muscle specific kinase.
Answered by Dr. Prasad Akole 12 hours later

With all this information - eye dryness, oral dryness, inflammations, unresolving problems, and many specialists unable to come to one diagnosis, I feel we also need to rule out auto-immune disorders as well. Eye syndromes like sicca/ Sjogren's need to be considered

And I could see your oral photos, but paperwork / reports are not loaded here. Can you load them here? If you have any problems in loading, you can post the reports to my attention (ATTN: Dr. Prasad Akole) and send across to YYYY@YYYY

Auto-immune diseases / connective tissue diseases can be caught with ESR; XXXXXXX blot assay, c-ANCA, p-ANCA, anti DS DNA tests, etc., initially. Please confirm with your doctor if all this was considered / tested.

Here in India, we work up patients really fast - within a week at good centres like ours. Of course, some diseases take time to be fully evaluated as they are slow chronic tricky presentations.

I understand you must be having hard time undergoing tests, but if something solid comes up, definitive treatments are available for most. Most such connective tissue / autoimmune diseases would respond to steroids. Also since you have mentioned about allergies, please see if you have tried round the clock anti allergics like fexofenadine. Steroids work even in allergic conditions. Verify if you have eosinophilia / allergy testing.

Thanks again and hope to have some positive test clues.

P.S: Muscle kinase is referred to as Creatinine phosphokinase (CPK) at most laboratories. I could confirm this if you can upload the test reports here.

Best Regards
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Follow-up: Have vocal cord motion disorder and gastroporesis. Is this viral related? 7 hours later
I think we ruled out most autoimmune problems. I have attached my reports which includes the report from my rheumatologist. I just had the muscle kinase test and the comprehensive metabolic testing done this morning, ordered by my neurologist. On Wednesday I will have the CT scan of sinuses and neck and the thyroid ultrasound. On Thursday, I will have the EMG.
Answered by Dr. Prasad Akole 28 hours later
I am sorry I am unable to see any reports. Please email them at YYYY@YYYY . In the subject line, please write Attention to Dr Akole.
Waiting to hear from you
Above answer was peer-reviewed by
Follow-up: Have vocal cord motion disorder and gastroporesis. Is this viral related? 19 minutes later
I just emailed again to the attachments email.

Thank you,
Answered by Dr. Prasad Akole 39 minutes later
I got your reports emailed to me by the XXXXXXX team.
I read them all.
Well, most common autoimmune diseases are ruled out as well as Sjogren/ sicca related antibodies are negative. But the picture is typical of sicca varieties of syndromes producing dryness of eyes and mouth/ throat.
your reports do not clearly mention any vocal cord paresis.

The muscle kinase was MuSK antibodies seen in thyroid disorder. I was referring to CPK (creatine phospho kinase) which is raised in some muscular disorders.
Eaton Lambert syndrome ( a myasthenia like but contrasting condition may occasionally present like this. especially when weakness of muscles is more with rest.)
Anyway you are undergoing a TFT, thyroid ultrasound, a CT PNS and neck and EMG.
Do you really feel that the throat and jaw muscles are weak or it is due to pain of inflammation?
and you did not mention any fever anytime?

You can go ahead with the tests and post me those test results. I really have nothing more to suggest right now, except to ask you to relax and not be anxious. You can take alprazolam as advised by your doctor to help you cope up.

The mouth problems will get better once the underlying disorder is addressed with treatment.

Please discuss about treatment with steroids with your doctors when you go to do the tests.
Awaiting your reply and a face+ neck photo if possible
keep smiling :)

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Follow-up: Have vocal cord motion disorder and gastroporesis. Is this viral related? 7 hours later
I think it could be inflammation. I feel it in my eyes now two like it is a sinus thing too. They only approved the thyroid test and ct of neck but not the sinuses.
Answered by Dr. Prasad Akole 3 hours later


Thanks for the picture. You look beautiful and perfectly normal and a good smile there too!!
I mean I am happy to see you smiling and not worried and to see that you have no obvious facial features to suggest any syndromes where typical facies are present.
It does give us a subtle clue to the diagnosis and no obvious thyroid goitre.

So for now I really would advise to stop worrying too much; take good rest. A very small dose of alprazolam (0.25mg) can be tried at night to feel stress free. Alprazolam will need a prescription from your doctor.

In addition you may use lubricating eye drops (artificial tears) as advised by your ophthalmologist to beat the dryness. Oral gels and something to chew to produce enough saliva to keep oral (mouth) cavity moist too will also benefit you.

I apologize if I was not able to give you more information, but sitting here I cannot offer any more authentic medical advice right now; I need to see the patient in person to do that. But many specialists there have done that quite well for me. Think positive and look at better things in life and get busy with something else (that is what I do to overcome my problems!):)
Your next testing will hopefully find / rule out something important for the diagnosis (almost all serious things are ruled out).

I will be glad to assist you further as the test results show up. Please be guided by your team of specialists in the US. They are doing a good job!
Please revert if any more doubts.

Good luck!
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Follow-up: Have vocal cord motion disorder and gastroporesis. Is this viral related? 17 days later
CT scan, thyroid ultrasound was normal. I had a video swalllow and the tech said she could see food sticking in the esophogus and when I drank water, she saw it wash away. Then the doctor looked at it and said it was normal. I was pretty upset. My stomach distension has gotten worse. I almost threw up eating breakfast this morning and it was small. I have dizzy spells again and my vision seems foggy, this was happening in december when this all started and I feel like back of my palate, mouth is stiff, having a hard time swallowing still.The tech said that I'm feeling like I have a hard time initiating the swallow but its really happening in the esophugus. I am going to see my gastro in two weeks to try and treat the gastroporesis. Its odd to me that the only thing that worked temporarily was the ketakazole back in march and all my symptoms seemed to go away temporarily. Why is that?
Also, my eyes seem to be getting dry and painful like they were when this all started.
I also started having really swollen gums.
Answered by Dr. Prasad Akole 22 hours later
Welcome back !
Good to read that the CT scan PNS and neck was normal as well as the thyroid USG as I had expected in my earlier communication.

What about the muscle kinase and EMG/ NCV studies? Were they done?

As you notice that your inflammation got better with ketoconazole or with fish oil, it could be due to the immune modulating effects of the two (though ketoconazole is primarily an anti-fungal).
I still think it could be some rare auto-immune disorder and would await your posting the latest test results to me.

If nothing is coming up, you can discuss with your doctors about trial of a short course of steroids which are good immune modifying agents of choice for most conditions where auto-immunity is present.

Also please consider my earlier suggestions about rarer disorders.
Try high dose vitamin C which is simple to use. Earlier advice by a ENT colleague about oral ulceration could also help symptomatic relief.

I will revert back once I see more reports from you.
Thanks for your persistence and efforts.
Above answer was peer-reviewed by
Follow-up: Have vocal cord motion disorder and gastroporesis. Is this viral related? 3 hours later
muscle kinase was normal as well has thyroid ultrasound. The doctor was hesitant on doing the nerve testing because if they were testing for swallowing disorders, she said that he should really be testing all four limbs so I tried to go back to the neurologist and havent received a call back yet to change the I am really hesitant about the test because I heard it is very uncomfortable.Also, I believe I had all of these tests, I would have to check with my dr again, but I saw a rheumatologist in April and they all came back normal.
Answered by Dr. Prasad Akole 27 minutes later
All right.
I think NCV/EMG are important tests remaining.
They are not that unfortable.
They may throw positive or negative light on the diagnosis.
Please revert with all the results.
Thanks !
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Follow-up: Have vocal cord motion disorder and gastroporesis. Is this viral related? 3 hours later
would you think that all four limbs should be tested?
Answered by Dr. Prasad Akole 6 hours later
I am not an expert in that field; but if your neurologist says it is needed, it is better done that way. It is a simple test and can give clues to solve your problem.

Are you taking any anxiolytics as advised earlier? A small dose of alprazolam (0.25 mg) at night may help.

Please try to look at the positive things in life and get rid of worried. People we see are a lot more badly affected with diseases. And we will do find a way to treat your problem. Some illnesses need time to get better.

If all my suggestions so far seem to be helping, may I ask you to rate the experience here and also write a review before you “Accept" the answer and close the query whenever you feel well satisfied?

Will revert if you need further help…

Take care.

Above answer was peer-reviewed by
Follow-up: Have vocal cord motion disorder and gastroporesis. Is this viral related? 35 hours later
My doctor said that all those tests were negative, I would try and stay positive, however I feel like my whole mouth is stiff and swells up and feel like I cannot swallow. When I try to eat something that makes me mucousy, it is uncomfortable because it feels like my mucuous membranes are all blocked. I feel like my head will explode one of these times, that's how awful it is, and feel like it is getting worse everyday. The nerve test is the last one I believe I have left. I do have my GI and ENT appt this week, so hope to be able to get my swallow study to them. Also, I take about .5 mg of the alzoprham, that helps me through the night and about 1/2 the day, that's it.
Answered by Dr. Prasad Akole 12 hours later
Hi there!

Please undergo the NCV/ EMG and let me know the results.

When you XXXXXXX your GI specialist, ask if a prokinetic and antiemetic like metoclopramide, domperidone or ganaton would be useful for gastroparesis (if it is really there).

Dry eyes, dry oral cavity and sticky saliva are common in inflammation due to many variants of autoimmune diseases. Some are difficult to diagnose and overlap syndromes exist.

If NCV/ EMG turn out non-contributory, this should be strongly considered and your rheumatologist would help.

Also, do discuss about steroids with your specialists, especially the rheumatologist.

Hope to read you soon with the results.
Take care.
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