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Monday, July 28, 2014
Ear, Nose, and Throat Disorders
Palpable click when swallowing
I am a 35 year old male. I smoked for approximately 15 years prior to quitting. The issue I am having is about 2 years I woke up with a very small, but noticeable, click in my throat. There was some trauma to the chin which occurred a week or two before the issue was noticed (I fell and hit the underside of my chin on a table). When it first appeared it was sporadic and, while noticeable, not painful. Since then it has become an extreme discomfort. Now when I swallow there is a palpable double click on the right side of my neck. It is uncomfortable, and is worse when I am lying down. Lately it has gotten so bad that it is interrupting my sleep. I also have difficulty swallowing.
I saw several doctors before I found one that realized it was causing me discomfort and did not dismiss the issue as being unimportant. Tests I have had (all normal) include a swallow study, CT (Hyoid looks ok) with and without contrast, a neurological exam, upper endoscopy, direct laryngoscopy, and a chest x-ray. I was also treated with a high dose of nsaids, but was quickly taken off of those when my creatinine started to rise (and they are now reluctant to try that again). Because of the issue with NSAIDS I was instead put on a regiment of steroids. Neither approach had an affect on the intensity of the click or the discomfort it causes. I have also gone through a regiment of PT to strengthen the neck - but it did not make a difference.
At the recommendation of my doctor I then saw the head of surgery for one of the universities in our area. He suggested the removal of the center portion of the hyoid (can`t remember what the procedure is called). I was reluctant to do a procedure that was based off of a guess (which the doctor admitted).
Since then I did discover and share with my doctor an article Throat Click: Fact or Fiction. My doctor had communications with the individual that did the study and found that an option might be surgery in which I was awake and he could observe the issue. While reluctant, I was getting desperate because this issue is only progressing and not getting better. I decided to look into this as an option and my insurance said they would not cover the procedure without a clear diagnosis and evidence of the issue (like a palpable double thump - which has gotten quit violent - is not evidence enough).
I apologize for the length of the message, and know that the content was similar to http://www.netwellness.org/question.cfm/30911.htm. However, I am really desperate to figure out where to go next. Are there different imaging techniques that can be done (I had seen one article about a 3d image reconstruction of the throat to find this issue. Was done somewhere in Germany and haven`t been able to find the article since)? Is there a specialist somewhere in the US that is recognized for this type of work? I am even considering paying for the surgery myself.
Any thoughts are greatly appreciated.
There are some abnormalities that can cause "clicking" in the neck and face. One of the most common is temporo-mandibular joint dysfunction. This is a problem of the jaw joint that can cause jaw, ear, and neck pain. From the history given, this is not likely here. The hyoid can also cause a neck click. This was evaluated with a CT that showed normal hyoid anatomy by report. One more cause is the thyroid cartilage (the main cartilage of the larynx) rubbing against the cervical vertebrae. Usually, it is the superior cornu (horn) that rubs against the transverse process of the cervical vertebra. During normal swallow, the larynx is lifted towards the back of the tongue. This is when the "click" happens. It can be hard to detect, especially if not suspected first. The cartilage is hard to see on x-rays (and in swallow studies with fluoroscopy), because it is not usually calcified at it's superior end. It could have been caused by trauma to the larynx. A CT can sometimes show a posteriorly displaced superior cornu. It can be treated by surgically removing the displaced piece of cartilage. An otolaryngologist with interest in swallow dysfunction (sometimes with specific training in laryngology--voice problems) may be able to help. Again, it can be hard to prove that this is what is causing the click. Any surgeon should be cautious about going to surgery without a definitive diagnosis, and the patient must be prepared to have a procedure that may not help the problem.
Michael J Wolfe, MD
College of Medicine
University of Cincinnati