Difficulty swallowing (sometimes referred to as dysphagia) is a common problem among all age groups, especially the elderly. Typical complaints of dysphagia include food getting stuck in the throat, inability to swallow pills, and/or regurgitation. Often patients will choke on bits of food, liquid, or saliva that are not passing easily. In more extreme cases, patients may aspirate foods or liquids that will spill into the lungs, causing pneumonia at times.
The process of swallowing is very complex and requires several structures to function properly in a coordinated fashion. Swallowing is broken down into three separate phases; the oral phase, the pharyngeal phase, and the esophageal phase. During the oral phase, food is chewed up, mixed with saliva, and voluntarily pushed towards the back of the throat (oropharynx). This initiates the pharyngeal phase which represents the food being passed from the throat (pharynx) to the esophagus (the food tube leading to the stomach). In the final phase, the food or liquid is carried down to the stomach.
Swallowing issues can structural, functional, or both. The most common structural issue is inflammation of the throat and esophagus. Inflammation can be caused acid reflux (GERD), radiation exposure (as with cancer treatments), allergies (eosinophilic esophagitis), or swallowing medications without enough fluid to wash them down properly. Other structural issues might include esophageal stricture (narrowing of the esophagus), anatomical abnormalities (such as a paralyzed vocal cord), or head and neck cancerous lesions. Functional issues are caused by inability to use the swallowing muscles appropriately, and may be caused by advanced age (presbyesophagus), stroke, and other neurological or systemic conditions.
Although swallowing issues rarely indicate a serious medical condition, a thorough upper airway examination is recommended to rule out worrisome findings or treatable causes. This can be accomplished by seeing an Otolaryngologist (also known as an Ear, Nose, and Throat physician), who can perform a quick and painless in-office procedure known as a laryngoscopy. The laryngoscopy, which is performed after spraying lidocaine in the nose and mouth, allows the physicians to evaluate vital structures including the vocal cords, epiglottis, and pyriform sinuses (opening into the esophagus), which may be contributing to the swallowing issues. Sometimes additional testing and evaluation may be required. One common test is called the barium swallow study, in which X-ray images are taken while a patient drinks a liquid known as barium. At times CT or MRI imaging can be obtained if there is concern about more worrisome findings. When the swallowing does not appear to involve the upper aerodigestive tract (larynx and pharynx), the patient may be referred to follow up with another specialist known as a Gastroenterologist (GI), who may perform an esophagoscopy to directly look at the esophagus. This test is usually done under anesthesia.
Treatment options for dysphagia tend to vary. For individuals who frequently choke on foods or liquids, slowing down the swallowing process can be helpful. Patients should chew foods slowly, sit up straight when swallowing, and stay upright 15-20 minutes after eating. Better management of acid reflux can also be helpful. This can be accomplished by avoiding spicy and acidic foods and taking medications such as omeprazole or ranitidine. Sometimes treating allergy disorders can be helpful. Many swallowing disorders can also be improved by the assistance of a speech and swallow pathologist who can initiate “swallow therapy”, which is like physical therapy for dysphagia. Speech pathologists can provide specialized exercises which can help strengthen the swallow reflex. At times structural diseases that are identified may be treated with surgery.
Opinions expressed here are those of our medical writers. They are not intended as medical advice and cannot substitute for the advice of your personal physician.
The thyroid gland is a small organ located at the front of the neck right below the larynx (Adam’s apple). The gland is shaped like a butterfly with two separate lobes and wraps itself around the trachea (windpipe). As a component of the endocrine system, the thyroid is responsible for releasing hormones (T3, T4, and calcitonin) into the bloodstream which help regulate metabolism, heart rate, body temperature, and blood calcium levels.
On many occasions, abnormal growths or lumps can develop on the thyroid gland. These are called thyroid nodules. Thyroid nodules can be solid or fluid filled. They can be found isolated or grouped with other nodules. Under most circumstances, thyroid nodules do not cause symptoms and go unnoticed to the patient. In rare cases, a nodule will become excessively large, and symptoms will develop, including difficulty swallowing, hoarseness, neck pain, or enlargement of the neck. Thyroid nodules are often found incidentally during routine examination or on imaging studies (MRI, CT, US) that are obtained for unrelated reasons, but these nodules will still need to be evaluated to ensure that they will not cause any problems. An abnormal thyroid function test may also indicate whether a nodule is present. Thyroid function tests measure the blood levels of T3, T4, and thyroid stimulating hormone (TSH). It is also important to know whether the thyroid hormone levels are normal, or higher or lower than expected, which can affect body function.
Although most thyroid nodules are consistent with benign disease (>90%), additional evaluation is important to ensure that that there is not anything more worrisome occurring. The first step in evaluation after physical examination is obtaining a neck/thyroid ultrasound, which gives accurate measurements of the size, shape and other important characteristics of the thyroid gland and any nodules that may be present. An ultrasound is a quick painless procedure that will give detailed information about the presence, number, size, and location of any thyroid nodules. Depending on the results, additional evaluation may be necessary. For nodules that are consider large (typically greater than 1-1.5 centimeter), a specialized biopsy technique called a fine needle aspirate (FNA) is often recommended to rule out worrisome findings. In many cases, an FNA is performed under ultrasound guidance, ensuring better accuracy. FNA results will often demonstrate whether or not a nodule is benign (harmless) or malignant (cancerous). When FNA results are indeterminate (uncertain), additional assessment is often necessary. A new technique that has recently been used to better determine the chance of malignancy in this situation is a specialized “genetic test”, which can help us place patients in low or high risk categories when previously we were unable to make an assessment. In those patients with nodules that are cancerous or high risk, we would recommend surgical removal of part or all of the thyroid gland.
Recent guidelines from the American Thyroid Association has shown that for some less aggressive thyroid cancers, removing only part of the thyroid gland may be appropriate, allow for quicker healing, less need for medications postoperatively, and afford similarly high cure rates.
If you or a family member have any concern regarding head and neck symptoms, please do not hesitate to contact Colden Ear, Nose, Throat, and Allergy to schedule and examination.
Humans are exposed to all kinds of sounds on a daily basis; including cars, engines, televisions, or radios. Under most circumstances, these sounds are at safe levels and do not affect our hearing. However, when we are exposed to loud noises, sensitive structures inside the inner ear can be damaged. This condition is referred to as noise induced sensorineural hearing loss.
Hearing is a complex mechanism which requires several structures to work together. The outer ear includes the pinna and external auditory canal. The pinna functions to collect sound waves and direct them into the auditory canal. Because of its unique structure, sounds are amplified as they travel towards the back of the auditory canal. The captured sound waves then reach the tympanic membrane (eardrum) at the back of the canal, causing it to vibrate back and forth. The eardrum represents the separating barrier between the outer and the middle ear. As the eardrum vibrates, three tiny bones behind it begin to shift with it. These tiny bones are considered the smallest in the body, and are called ossicles. The last tiny bone, commonly referred to as the stapes, then transfers the vibrating motion to the organ of hearing, the cochlea. It is inside the cochlea where tiny structures called “hair cells” convert the vibrating energy into an electrical signal. The signal travels to the brain where perception occurs.
When noises are too loud, the tiny hair cells within the inner ear are damaged and eventually die. This results in decreased hearing. Noise induced hearing loss can be caused by a one-time exposure to an intense sound (such as a blast) or by continuous exposure to loud sounds over an extended period of time (working in a loud shop). Leisure activities can also put one at risk for noise induced hearing loss. This might include listening to MP3 players at high volumes or attending loud rock concerts.
There are many other causes of hearing loss besides noise, and these causes include aging (presbycusis), genetics, disease (history of recurrent middle ear infections, viral inner ear infections, and Meniere’s disease), and trauma .The severity of hearing loss depends on all of these factors , which can co-exist and be additive. Individuals with a mild hearing loss might only experience difficulty hearing with background noises. Individuals with a severe hearing loss may experience difficulty during normal conversation, which can impact their personal and professional life significantly. Another common symptom of hearing loss is ringing or buzzing in the ear, which is referred to as tinnitus. Tinnitus will often come and go, and can be extremely bothersome to patients. Machines that create masking sounds (white noise) can be used to “cancel-out” the tinnitus in many cases.
Noise induced hearing loss is the only type of hearing loss that can be completely prevented. The best way to do so is to avoid loud noises. If one cannot avoid excessive noise, hearing protection is recommended. Ear plugs or ear muffs are frequently used to help decrease loud noises.
Proper assessment of hearing loss requires a hearing evaluation. If one suspects that their hearing has decreased it is important to see an otolaryngologist (Ears, Nose, and Throat physician) or licensed hearing professional who can perform a specialized hearing test. Depending on the results and exam, a patient may be a candidate for a hearing aid or other assistive listening devices. Other modalities include fabricating a custom ear plug that can minimize additional noise exposure if one is routinely exposed to loud noises at work or during hobbies (i.e. musicians). If a patient wishes to pursue hearing aids, a hearing aid evaluation is set up. During a hearing aid evaluation a trained audiologist or hearing instrument specialist will meet with the patient and help them find a hearing aid model which works best for them.
If you have any questions about Noise Induced Hearing Loss or want to set up an evaluation with one of our Board Certified Ear Nose Throat specialists, or licensed audiologists or hearing instrument specialists, please contact us at Colden Ear Nose Throat and Allergy at 978-997-1550, or through our website.
Springtime has arrived and so have spring allergies. The spring is notoriously referred to as the “tree allergy season”. With warmer weather comes the onslaught of tree pollination. Billions of tiny airborne pollen particles are released into the environment and are carried great distances by the winds. As the pollen particles waft through the air they are easily inhaled by allergy sufferers which trigger a series of bothersome symptoms. This condition is sometimes referred to as “Hay Fever,” or seasonal allergic rhinitis, and affects roughly 30 to 60 million people in the United States on an annual basis.
Seasonal allergies can cause a variety of symptoms. The most common include recurrent sneezing, a runny nose, watery/itchy eyes, and nasal or throat congestion. Severe allergies may cause polyps to form in the nose and sinus, further blocking the ability to breathe comfortably through the nose and triggering recurrent sinus infections. Conditions associated with hay fever include asthma, eczema, conjunctivitis, nasal polyps, sinusitis, sleep apnea, laryngitis, and ear infections. Individuals with asthma may become more symptomatic when exposed to tree allergens, and often report increased wheezing, shortness of breath, or coughing. Another strange symptom that may indicate that you have seasonal allergies is itchiness of the mouth and throat after eating raw fruits (apples, bananas). This condition is called oral allergy syndrome and is highly prevalent in individuals with tree allergies such as birch.
The first step in minimizing spring allergies is to determine which trees you are sensitized (or allergic) to. An allergy test determines whether your body has an allergic reaction to a specific substance in the environment, in this case tree pollen. Because tree pollen particles have very unique proteins (and therefore have less cross-over between different types of trees), patients are often tested for several different tree species, usually dependent on which trees are found in their region. A tree allergy test panel for New England may include oak, elm, maple, sycamore, and birch to name a few of the more common tree pollen offenders. Allergy testing can be performed either via a quick pain-free skin test or by a blood test. Both types of testing are safe and can be effective for diagnosing tree allergies, as well as other types of allergies. Skin testing has the advantage of being performed in the office setting, and other benefits may include: immediately available results, the ability to test for multiple tree allergens, and the immediate patient feedback regarding how they react to certain tree pollens in their environment. In preparation for skin testing, patients are advised to discontinue taking antihistamines and other types of medications that may interfere with test results.
Tree allergies can be treated in variety of ways. Firstly, environmental modifications are recommended for anyone who is allergic to pollen. This includes keeping home windows closed, staying indoors on high pollen days, not drying clothing outside, and showering before bedtime. If environmental modifications are not enough, medical management may be necessary. This includes over the counter antihistamines (e.g. Claritin, Zyrtec) and intranasal steroid sprays (e.g. Flonase). Other types of medications include nasal inhaled antihistamines, mast cell stabilizer nasal sprays, and oral decongestants.
For patients who are interested in additional improvement and decreasing their usage of allergy medications, immunotherapy should be considered. Immunotherapy can be given in two different ways, including subcutaneous immunotherapy (SCIT or allergy shots) and sublingual immunotherapy (SLIT or allergy drops). SCIT (allergy shots) has shown repeatedly over the past 50 years to be a very safe and effective way to minimize both seasonal and year round allergies. SLIT (allergy drops) is the most common form of allergy treatment in Europe, and has been shown to be as effective and safe as traditional allergy shots, but has the added benefit of being able to do this treatment in the convenience of your home (you can self-administer the drops daily). The major disadvantage of SLIT is that it is currently not FDA approved in the USA (although the drops are made from the exact same allergy extracts that are used to create the allergy shots), and therefore this treatment would not be covered through medical insurance.
If you or a family member have any concerns regarding spring allergies, please do not hesitate to contact Colden Ear Nose Throat and Allergy and schedule an allergy evaluation as your first step towards symptom relief.
Opinions expressed here are those of Dr. Daryl Colden and Christopher Jayne, BA. They are not intended as medical advice and cannot substitute for the advice of your personal physician.
