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What causes feeling of something stuck in throat and cricopharyngeal spasm?

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Posted on Mon, 9 Feb 2015
Question: Dear Doctor,
I'm suffering from constant syndrome of something stuck at the base of my throat for months. The syndrome is very strong and intolerable. It has affected my life quality seriously and also my emotional stability.
I was once diagnosed with mild reflux according to gastroscopy result in Aug 22 2014, and have been taking various medications to treat it after that and until now. I had another gastroscopy in Nov 21 2014 which shows improvement in esophagus(looks normal).
Although I'm taking reflux medications all the time, my heavy syndrome in throat only got improved for a few days when I first took reflux medications, and then my throat syndrome just keeps the strong intensity. Besides, my throat syndrome once disappeared right after a pipe was put into my esophagus to do esphagus manometry in Oct 2014. In addition, my throat syndrome is much reduced when I burp or swallow solid food (not reduced for liquid drink). I had no other reflux syndrome of acid coming out or burning heart. My only syndrome is the strong feeling that something is stuck in my throat.
According to my condition, I am wondering if my current throat syndrome is due to the reflux? How come there is no improvement of my syndrome when I've taken various reflux medications for months and it shows improvement in gastrocopy? How I should continue with reflux treatment? What elso can I do to find the reason and therefore possible treatment to reduce my throat syndrome?
Attached please find a summary of my medical history record with more details, also my medical reports.
Thanks a lot.
XXXX
doctor
Answered by Dr. Sumit Bhatti (6 hours later)
Brief Answer:
Globus pharyngeus. Multi-factorial.

Detailed Answer:
Hi,

Thank you for your query.

1. From your history and reports, the feeling in your throat is best described as a 'globus' sensation. It seems to be a multi-factorial problem.

2. Since you have been on anti-reflux medication from several months, only reflux is not the cause. One of the causes of feeling something stuck in the throat is reflux of digestive enzymes which get activated whenever the pH falls in the throat and leads to local inflammation.

3. Cricopharyngeal (Upper Esophageal Sphincter) spasm is a known cause. This would explain why you feel better after burping or swallowing food. However the esophageal manometry should have picked up higher esophageal pressures.

4. Thyroid disorders are linked and if the thyroid surgery has indeed caused any fibrosis or changes in the neck, a dynamic (cine MRI) and CT Neck Scan will have to be co-related with physical palpation.

5. The list of possible causes for these symptoms is large, hence if you could begin with ruling out these causes, further discussion can take place. Also rule out sleep apnea (snoring), dryness in the throat, elongated styloid process (Eagle's Syndrome) and any tongue base enlargement.

I hope that I have answered your query. If you have any more questions I will be available to answer them.

Regards.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Sumit Bhatti (1 hour later)
Dear Dr. Bhatti,

I understand my condition is quite complex. Really thanks for your reply.

With regard to your explanations, I have the following questions to ask for your advice.

1. Should I continue reflux medication? Which one and what is the dosage? I have a bit discomfort in stomache while taking Nexium/Pantoloc/Dexilant (the feeling of pressing down), and am thinking to stop it for a while. Is it OK?

2. Since the esophageal manometry result in Oct is normal, can cricopharyngeal (Upper Esophageal Sphincter) spasm be ruled out? Or should I redo the test?

3. Regarding throid surgery related factor, can it be seen from the neck ultrasound? I have pictures of the neck ultrasound and wonder if doctor can read it to find some clue. Or, do I need both a dynamic (cine MRI) and CT Neck Scan, or either one, to diagnose it? FYI, I've had physical palpation by an ENT specialist and a family doctor, and they found nothing abnormal.

4. My current blood test results are normal. But, can the change in metabolism after surgery be the cause of this throat syndrome? If yes, what can be further done to investigate it?

5. Sleep apnea (snoring): I snore but it's not heavy, and I'm the same before and after surgery. Can sleep apnea be ruled out?

6. Dryness in the throat: I do feel dryness in uppper throat area, but not serious, and I feel the same before and after surgery. Can it cause this syndrome at the base of the troat? My family doctor has given me "Avamys - fluticasone furoate nasal spray, a corticosteroid for nasal use". Should I try it?

7. Elongated styloid process (Eagle's Syndrome) and any tongue base enlargement: I don't know I have these problems before surgery. Is it possible I catch them after surgery? What do I need to do to rule them out or diagnose them?

With my multi-factorial condition, what specialist do you think I should I go to see?

Thanks a lot and look forward to your reply.

Best regards,
XXXX

doctor
Answered by Dr. Sumit Bhatti (51 minutes later)
Brief Answer:
Multiple investigations are needed.

Detailed Answer:
Hi,

Thank you for writing back.

1. Since you have been on anti-reflux medication since many months, it is fine to taper it down or stop it for a while. The usual duration of initial therapy is 8 to 12 weeks. If there is no response and despite lifestyle and diet modifications, a sliding hiatus hernia and h.pylori infection are ruled out as in your case by a normal endoscopy and biopsy test. There are other anti-reflux medications such as rabeprazole and levosulpiride that can be tried out by your doctor. I have also seen patients who have been taking anti-reflux medications for decades.

2. Repeat the esophageal manometry and get a dual probe ambulatory esophageal pH testing done. Negatives tests in medicine do not rule out an underlying condition.

3. Neither the neck ultraound nor neck palpation can reveal the subtle changes following neck surgery. In fact, even the scans will show greater detail, but they cannot show function. Hence esopahgeal motility studies such as a barium swallow will help.

4. More than any change in metabolism, any change in thyroid levels and changes in BMI (Body Mass Index) will be of consequence.

5. Get a Sleep Study or Polysomnogram done to check if the snoring is significant.

6. Dryness, dehydration and decreased salivary production can lead to such symptoms. Your doctor has prescribed the nasal spray to decrease any Post Nasal Drip that may be responsible for your symptoms.

7. Eagle's Syndrome and tongue base hypertrophy will show up in the scans.

I hope that I have answered your query. If you have any more questions I will be available to answer them.

Regards.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Sumit Bhatti (1 hour later)
Hi, I have provided some attachments. Please review them.

Dear Dr. Bhatti,

Thanks a lot for your prompt and detailed reply. Based on my condition and feeling of the syndrome, I suspect that the spasm of esophageal sphincter can be a major reason for my syndrome, while other factors need to be further explored. I have a few more questions to ask for your advice:

1. My throat syndrome dissappeared right after a pipe was put into my esophagus through my nose to do esophageal manometry in Oct. The good situation remained for 1 day during when I was wearing a thin pipe from nose into throat to do the 24hr throat pH testing right after the esophageal manometry. What does that mean? What can be the reasons behind? Is it the same indication as that my syndrome is reduced when I burp or swallow solid foods?

2. What is the cause of the spasm of esophageal sphincter? Can it be shortage of certain elements? My calcium level is normal according to recent blood test, but should I do more blood test such as magnesium, certain vitamin or something else?

3. Can reflux be the cause of the spasm of esophageal sphincter?

4. What can be done to treat the spasm of esophageal sphincter?

5. My throat syndrome was once reduced for 10 days when I was taking Nexium together with Metoclopramide in end Sept/early Oct. Is Metoclopramide a medication to treat the spasm of esophageal sphincter? Should I try it? If yes, what's the dosage?

6. Can the spasm of esophageal sphincter gives you the syndome of something stuck at the base of throat all the time/non-stop?

7. Can the spasm of esophageal sphincter last for years as reflux do?

Sincere thanks.
XXXX
doctor
Answered by Dr. Sumit Bhatti (6 hours later)
Brief Answer:
Barium swallow, FEES, FEEST. Trial with a pro-kinetic.

Detailed Answer:
Hi,

Thank you for writing back.

1. The probe channel inserted into the esophagus alters the tone of the cricopharyngeal sphinter and allows gases to escape. That is why you felt better.

2. The spasm is usually due to chronic inflammation secondary to chronic reflux, cervical spine changes with age, anxiety and may a times unexplained.

3. Nutritional deficiencies are easily tested and replenished. Get your Vit. B12, magnesium and Vit D tests done.

4. Metoclopramide is a gut motility enhancer and anti-emetic. Hence the suggestion to try out levosulpiride. or domperidone. This response will go more in favour of an esophageal motility issue than a spasm.

5. Yes, all these symptoms can be a result of mild cricopharyngeal spasm (since your esophageal manometry is within normal limits) or esophageal motility problems.

6. Globus pharyngeus can last for years before settling down. Botox injections can help if the spasm is confirmed at some time. Get the barium swallow study or the newer FEES (Flexible Endoscopic Evaluation of Swallowing) / FEEST (Flexible Endoscopic Evaluation of Swallowing with Sensory Testing) procedures done.

I hope that I have answered your query. If you have any more questions I will be available to answer them.

Regards.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Sumit Bhatti (9 hours later)
Dear Dr. Bhatti,

Thank you very much. It's very informative and valuable to me, making me clear about next steps.

I have several more questions:

1. I understand that reflux can be a major cause of cricopharyngeal spasm. If reflux is getting better or has gone away, can cricopharyngeal spasm continue? So that you'll need to have separate treatment to deal with it.

2. What can help determine if I still have reflux? I think my syndrome and gastroscopy can help to some extent. Will dual probe ambulatory esophageal pH testing help? Or what else?

3. In terms of medication, I would stop reflux medication for a while to see the response (keep my diet and lifstyle unchanged). While, if to take medications, should I take PPIs (Nexium/Pantoloc/Dexilant/Rabeprazole) together with gastric motility medications (levosulpiride/domperidone), or with digestive enzyme? Or should I try only one medication each time?

Thanks you so much.
XXXX


doctor
Answered by Dr. Sumit Bhatti (2 hours later)
Brief Answer:
Lesser reflux decreases the spasm. Do the tests. PPI+gut motility enhancers

Detailed Answer:
Hi,

Thank you for writing back.

1. Cricopharyngeal spasm should reduce if reflux was the only cause. Some of the contributing causes are not known.

2. Yes, the tests I have mentioned will help make the diagnosis clearer.

3. You may stop the ant-reflux medication for a while. If you have to re-start, take both PPIs and gut motility enhancers together.

I hope that I have answered your query. If you have any more questions I will be available to answer them.

Regards.
Above answer was peer-reviewed by : Dr. Vinay Bhardwaj
doctor
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Follow up: Dr. Sumit Bhatti (32 minutes later)
Dear Dr. Bhatti,

Thanks you very much, I am not very clear about what to do next.

To summarize, I'll stop Dexilant for a while to see the response, try the nasal spray, do FEEST/FEES or barium swallow study, redo esophageal manometry and dual probe ambulatory esophageal pH testing, get blood test of Vit. B12, magnesium and Vit D done, do dynamic (cine MRI) and CT Neck Scan to see more details of post-surgery condition and rule out elongated styloid process (Eagle's Syndrome) and any tongue base enlargement, and maybe a Sleep Study or Polysomnogram to rule out sleep apnea (snoring). In the meanwhile, I will go to see a pyschologist and try to relax as much as possilbe myself to reduce the factor of anxiety that may play a role in my syndrome.

I really appreciate very much of your professional advice and willingness to help. I am now more confident in finding the underlying reasons and therefore the treatment to my syndrome, to make my life back to normal. I wish that I can have further contact with you for advice after I've done the above.

Sincere thanks and best wishes,
XXXX

Dear Dr. Bhatti,

One thing suddenly came to me to ask for your opinion.

The syndrome of something stuck at the base of my throat has been in the middle location for months. But just now, the location of the syndrome changed to the right side of my throat. I feel nothing in the left side of my throat now. It has been 2 hours like this and I'm not sure how long it will last.

Does it indicate anything? I'm thinking maybe it should be more related to spasm of esophageal sphincter, rather than post-surgery scar tissue? Or does it mean that certain factors should be ruled out?

FYI, I remembered that the location had changed sometimes at early stage when I developed this throat syndrome in Aug/Sep. At that time, the syndrome came and went. And there were several times that I suddenly felt something stuck at the throat right after I ate some sticky food or food hard to digest, since I was in hypothyroidism at that time and therefore had a weak stomache.

Much thanks.
XXXX

Dear Dr. Bhatti,

I forgot to mention one thing. My throat syndrom is usually even more serious when it is close to/during menstruation, or at ovulatory period. I'm not sure if it means anything.

XXXX


doctor
Answered by Dr. Sumit Bhatti (21 hours later)
Brief Answer:
Yes, follow this plan.

Detailed Answer:
Hi,

Thank you for writing back.

1. Yes, your understanding of the plan for examination, investigation and treatment is correct.

2. The change in the position of the discomfort signifies changes in muscle spasm and also that areas can recover.

3. Muscle spasm will change as per the menstrual cycle just like menstrual cramps. This is proven fact.

I hope that I have answered your query. If you have any more questions I will be available to answer them.

Regards.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Sumit Bhatti (30 minutes later)
Dear Dr. Bhatti,

Thank you so much for the clear answer. You've given me more confidence and I'll take actions accordingly.

My best wishes,
XXXX
doctor
Answered by Dr. Sumit Bhatti (5 minutes later)
Brief Answer:
Thank you for your wishes.

Detailed Answer:
Hi,

Thank you for writing back.

Wishing you a speedy recovery and good health.

Regards.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Sumit Bhatti (20 hours later)
Dear Dr. Bhatti,

This is to share with you one fact I just realized that can be related to my condition.

I had serious spasm from head to upper stomache/esophagus area two days after the surgery of thyroidectomy. It lasted 2-3 hours each time, and happened a couple of times each day. I was told that it was due to the temporary hurt on parathyroid during surgery and therefore the low calcium level in the body. The spasm lasted for serveral days and then went away, and I had chest discomfort/tightness for a few more days. I think it may be a cause of the spasm of esophageal sphincter, together with reflux and significant hormone level change after surgery. I also have siginicant change on body weight and the pattern of menstruation, and more hair loss after surgery that may indicate my significant hormone level change.

BTW, my throat discomfort is still at the ride side, and I realize that the downward pressure I sometimes feel at esophagus/upper stomache area may be the so-called "chest pain" which is a typical symptom of the spasm of esophageal sphincter.

Sorry I may be kind of wordy. But you are the doctor who really looks into the complex situation and gives analysis/action plan/treatment synthetically that I can talk to.

Thank you very much,
XXXX
doctor
Answered by Dr. Sumit Bhatti (1 hour later)
Brief Answer:
Get the operating surgeon's and an endocrinologist's opinion.

Detailed Answer:
Hi,

Thank you for writing back.

1. It depends upon the type of thyroidectomy. In total thyroidectomy any handling of the parathyroid glands (or inadvertent removal of some) would cause temporary fall in calcium levels ans spasms. Thus usually recovers within a few weeks.

2. There is also some degree of handling of the inferior constrictor muscle (including the cricopharyngeus) and upper esophagus along with the nerve supply which is closely related to the thyroid gland. Discuss this with the operating surgeon and get a second opinion.

3. The thyroid is known as the master endocrine gland of the body and hence its removal is associated with multiple symptoms. Discuss these symptoms with an endocrinologist.

4. As mentioned before, there are many tests to be done before this can be considered a cricopharyngeal spasm.

I hope that I have answered your query. If you have any more questions I will be available to answer them.

Regards.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Sumit Bhatti (27 minutes later)
Dear Dr. Bhatti,

Yes, I shouldn't be too quick to jump to conclusions myself. The most important thing now for me is to do those tests to see the result, and make efforts to reach the related specialists to get their opinion.

I know that I have a long way to go, while I feel that I'm making progress with your kind help.

Thank you so much,
XXXX

doctor
Answered by Dr. Sumit Bhatti (3 hours later)
Brief Answer:
Yes, that is the right way forward.

Detailed Answer:
Hi,

Thank you for writing back.

1. Yes, that is the right way forward.

2. A systematic approach will help you achieve progress.

Regards.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Dr. Sumit Bhatti

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Practicing since :1991

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What causes feeling of something stuck in throat and cricopharyngeal spasm?

Brief Answer: Globus pharyngeus. Multi-factorial. Detailed Answer: Hi, Thank you for your query. 1. From your history and reports, the feeling in your throat is best described as a 'globus' sensation. It seems to be a multi-factorial problem. 2. Since you have been on anti-reflux medication from several months, only reflux is not the cause. One of the causes of feeling something stuck in the throat is reflux of digestive enzymes which get activated whenever the pH falls in the throat and leads to local inflammation. 3. Cricopharyngeal (Upper Esophageal Sphincter) spasm is a known cause. This would explain why you feel better after burping or swallowing food. However the esophageal manometry should have picked up higher esophageal pressures. 4. Thyroid disorders are linked and if the thyroid surgery has indeed caused any fibrosis or changes in the neck, a dynamic (cine MRI) and CT Neck Scan will have to be co-related with physical palpation. 5. The list of possible causes for these symptoms is large, hence if you could begin with ruling out these causes, further discussion can take place. Also rule out sleep apnea (snoring), dryness in the throat, elongated styloid process (Eagle's Syndrome) and any tongue base enlargement. I hope that I have answered your query. If you have any more questions I will be available to answer them. Regards.