Brief Answer:
Bulbar ALS concerns

Detailed Answer:
Good morning ma'am. My name is Dr. Dariush Saghafi and I am a neurologist from the XXXXXXX OH area. I've read your concerns about your husband's swallowing issues and having to always clear his throat. You are worried that the clearing of the throat could signify the onset of bulbar ALS. He has been seen by ENT who placed him on medications typically used to treat asthma attacks as well as reflux disease but with apparently no improvement. He's had what sounds like a laryngoscopy without any significant findings.

Your questions essentially revolve around the astuteness of the specialist to pick up on whether or not something like this could have a neurological component to it or not. Obviously, that's a tough question to answer since the better person to ask those very direct questions would be the specialist himself. Personally, I think your questions are reasonable ones though I don't know enough yet about your husband's case to judge whether simply based upon the symptom of frequent throat clearing, bulbar ALS fits high into the list of possibilities of consideration.

I would say that the fact that the scopes did not show anything suggests that vocal cord movements and I'm also assuming epiglottal function have been judged as being normal by the specialist.

I'm sure there are some ENT's who look for other signs of ALS when they may suspect it in appropriate patients and likely just as many who don't. It's really difficult to make a comment as a neurologist on how much another specialist looks for "red flags." I would HOPE that they would look for obvious things such as uvular deviation and muscle atrophy if it existed. Again, for what it's worth if the laryngoscopy was normal then, I think it's safe to say that muscle bulk and function is intact from the mouth to the throat and into the vocal cord region.

I would also think it reasonable to assume that a good ENT specialist would ask for help from a neurologist if he had any index of suspicion that he were dealing with a potential case of ALS or any other neurological problem.

But there again, many variables come into play and I simply can't vouch for the particular one your husband saw has those sorts of instincts or tendencies or not.

I think your best course of action is to speak directly with the doctor who saw your husband and examined him and to ask the exact questions you just asked to get his direct answers to whether or not he noticed or took note of the NEGATIVE presence of any and all of your concerns having to do with the diagnosis.

Here is a quick little thing that may interest you to read about bulbar ALS:

http://www.als.ca/sites/default/files/files/Bulbar%2520ALS.pdf

I will say just a couple of things for you to consider. The average age of onset of ALS is between 60-65 years and so while I do see patients in their 40's and have seen younger, it is not even close to the norm....so, in my opinion, 47 is early for your husband to be having such a problem. Having said that, if he has a first degree relative with diagnosed ALS then, I retract that statement in deference to more information necessary.

Also, bulbar ALS forms are more commonly seen in women compared to men. Bulbar ALS only occurs in about 1/3 of people with ALS so again, just on probability of the age of your husband being younger than the norm and picking a subtype of ALS which is only seen in 1/3 of patients with ALS makes his likelihood of having the disease even less.

However, at the end of the day you and he would like to know, "What's causing these throat clearing problems...." I notice you didn't say anything about XXXXXXX choking or drooling which are 2 cardinal signs of a swallowing disorder of importance. Allergies, GERD, and other problems of a much more benign nature compared to ALS are for more common reasons for throat clearing and increased "phlegm" so to speak than ALS.

So to go full circle here are my suggestions:

1. Speak with the ENT specialist or your primary doctor about the questions you asked in this piece and get direct answers from the horse's mouth, the doc himself.
2. If he satisfactorily convinces you that he looked for signs of things other than GERD and allergies, asthma, and so forth then, perhaps your concerns can be allayed and put to sleep.
3. If you are not sufficiently convinced by the doctor that they looked enough at these other features (most of which are actual late features- such as tongue fasciculations) then, you should get an appointment for your husband to see a neurologist or ALS specialist straight away who will likely want to do testing in order to firmly answer your question if there are any doubts in his clinical examination or the history of what's going on.

If the information above has been of help to your concerns I'd appreciate a small amount of written feedback and a STAR RATING on what I've sent you as this keeps the colorful stickers coming from the network bosses! LOL!

Also, I'd greatly appreciate your CLOSING THE QUERY on your end if you have no further questions or commentaries on this response so that it may be processed, archived, and credited appropriately for future reference.

I also would like to invite you to look me up in the future with any other questions that you feel I may be able to assist you with by searching for me by name on this network (DARIUSH SAGHAFI) or you may also find me available to give consultations by webcam and live conferencing over the internet at:

www.healthtap.com/drsaghafi

My hours are generally early in the morning (VERY EARLY IN THE MORNING!) Wed-Sat. 3a-6a (ET; NEW YORK CITY TIME) and Sunday nights 11p-3a. I am also sometimes available at other times which you can find out by simply into the service, searching for me by name (DARIUSH SAGHAFI) and seeing whether or not I'm online. If so, you can ring me for a consultation and we can connect by webcam if you'd like.

All the best to you and your husband. Be well!

This query required 76 min. of physician specific time for review, research, and final documentation of draft for envoy.

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