[DYSPHAGIA] Male patient

[eripley@yahoo.com (Irene Campbell-Taylor)]

Kim
There appear to be several issues here. The report of
"apples sticking" is so suggestive of
globus=esophageal dysmotility that one can't help but
assume that the constant throat clearing is also GER
related (very common.)Constant hoarseness and vocal
fold edema would suggest suprapharyngeal reflux.
Do you know how he got  Hepatitis B and C? Could he be
a  needle drug user? See following:
A simple sore throat? Retropharyngeal emphysema
secondary to free-basing cocaine.Riccio JC; Abbott J.J
Emerg Med, 8:709-12.1990 
A case of retropharyngeal emphysema associated with
drug abuse is presented. Although chest symptoms of
pneumomediastinum have been widely reported with
substance abuse, pain localized to the neck is rarely
described. In the present case, localized dysphagia
was the only complaint, and no free air could be
demonstrated within the thorax. For uncomplicated
cervical emphysema or pneumomediastinum due to
substance abuse, extensive workup may be unnecessary,
and conservative therapy, including administration of
100% oxygen and observation is recommended if
resolution is prompt.

Hillstrom RP; Cohn AM; McCarroll KA. Vocal cord
paralysis resulting from neck injections in the
intravenous drug use population.Laryngoscope,
100:503-506  1990 
Intravenous drug use patients present to the head and
neck surgeon when injections are directed "in the
pocket," or more appropriately, toward the internal
jugular vein in the neck. The more common
complications of this practice include the development
of cellulitis, abscess, and venous thrombophlebitis
and, potentially, pulmonary embolism and
pseudoaneurysm of the carotid and subclavian arteries.
Vocal cord paralysis as a result of neck injection in
the intravenous drug-using population is rarely
described, and a review of the literature has yielded
only two reports addressing this uncommon phenomenon.
During a 7 1/2-year period between October 1981 and
June 1989, nine patients presented to Detroit Medical
Center with hoarseness, upper-airway obstruction, or
both following the injection of heroin or related
substances into the neck. Otolaryngologic evaluation
demonstrated unilateral or bilateral vocal cord
paralysis coincident with recent neck injections. The
clinical signs and symptoms, location of the
injections, acute management, and subsequent
complications are catalogued. Acute management of
these patients consisted of airway assurance via
tracheotomies when indicated and observation for the
development of cellulitis, abscess, or more
life-threatening neurovascular complications.
Follow-up laryngeal examinations ranged from 4 months
to 4 1/2 years and found no demonstrable return of
vocal cord function in any of the nine patients.

As to the clicking in the throat:
Clicking in the Throat  ;Cinematic Fiction or Surgical
Fact?  
Marshall E. Smith, MD; Gerald S. Berke, MD; Steven D.
Gray, MD; Heather Dove, MA; Ric Harnsberger, MD
Arch Otolaryngol Head Neck Surg. 2001;127:1129-1131
A description of 11 patients with audible clicking in
the throat with pain when swallowing or turning the
neck. Five had onset as the result of an accident, two
after intubation. The main source of the click was the
cornu of the thyoid cartilage, displaced posteriorly
and medially. One had clicking of the thyroid against
the hyoid. The location could be found by careful
palpation of the neck. Treatment was surgery.
This could certainly result from a kick to the neck.

I would ask ENT to look for any trauma to the vocal
cords and for any misalignment of thyroid and/or
hyoid.
Irene.

=====
www.dricampbell-taylor.com

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