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

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

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

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

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

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

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

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