ikandy, I too have swallowing difficulty that started about
3 1/2 years following a nissen fundoplication. Pasted below is a posting I placed on another blog. I suspect we have a similar problem in that we both have trouble swallowing saliva which is unique compared to the more common swallowing disorders. Please read my post and let me know if you share any common symptoms, have any questions, or have any suggestions. If you want to email me directly, my email is email@example.com
I'm 45 yr old white male living in metro Atlanta. I'm 5-9, 175 lbs, I am presently taking Levoxyl 0.112 daily for low thyroid for past 3 years. I also take Cymbalta for past 2 years for mild depression along with Androgel for low testosterone (been taking for past 5 years) and Adderall XR for Adult ADD (also taking for past 5 years). I have also been treating asthma symptoms for past 10 years. I had sinus surgery in '98 to correct a deviated septum, Nissen Fundoplication in 2001, Tongue reduction in '07, UPPP together with Septoplasty in '08 unsuccessfully to treat obstructive sleep apnea.
Also, in early 2004 I had a cosmetic chin implant added to augment my naturally recessed chin. ( I do not recall exactly when these swallowing symptoms started as they came on gradually but they did start not long before, or not long after the chin implant was done.)
My primary complaint surrounding my swallow is that I have residual material remaining in my lower throat after I swallow. I estimate 95 to 98% of whatever I am trying to swallow goes down fine with 2 to 5% remaining somewhere in my lower throat. This residual material can be either solid food particles, incompletely swallowed saliva, or incompletely swallowed liquids. The presence of this residual material makes me short of breath and difficult for me to breathe. I sometimes inhale the residual food particles or residual pooled liquids and cough and choke but more often or not, I sense the residual material and automatically go into a careful shallow breathing mode, during this shallow breathing mode, any physical activity makes me short on breath. Whether this residual material is scattered small solids (like ground beef or chewed nuts), single solid piece (like a pill or small piece of steak) or is simply pooled frothy liquid or saliva/phlegm, repeated dry swallows will not get it down. Similarly, drinking liquids will not wash down the residual material either.
The above described swallowing problem has existing for past 4 to 5 years and has become progressively worse in spite of Radio Frequency Tongue Reduction surgery in January of '07, Lower Esophageal dilation in 07, upper Esophageal dilation in 08 (it's possible my ENT Dr didn't actually stretch my UES as he's absent minded and may have forgot to do the stretch during the mid '08 Esophagoscopy w/biopsy after he saw the "burned tissue" in my lower throat and esophagus.) The "burned tissue" biopsy turned out fine. I suspect this burned tissue was caused by me habitually drinking large quantities of extra hot liquids which I find works better than anything to wash down the trapped residual material. After being advised on the "burned tissue" I have backed off on the extra hot liquids both in regards to temperature and quantity.
I have had three Modified Barium Swallow studies. The first one (November of '06) revealed extraneous tissue attached to my epiglottis that was further spotted on a subsequent CT scan . However, my ENT could not find any extraneous tissue during a fiber-optic examination of my throat so he dismissed the MBS study and CT scan as being a "fluke."
At this point I went to another practice (Emory Voice at Crawford Long Hospital) who, based on their fiber optic examination of my throat, said it was my lingual tonsil on my tongue base that was the extra material appearing on the first MBS and recommended a Radio Frequency Tongue Reduction along with a trimming of my epiglottis. On the morning of the Jan '07 tongue reduction/epiglottis trim surgery, the Doctor told me decided he didn't want to trim the epiglottis at the same time so only the Tongue reduction was performed. Several months later, I still had residual material in my lower throat so a second MBS was ordered which did reveal some residual liquids or fluids pooling in the vallecular space and pyriform sinus cavities. Based on this the Epiglottis trim was re-recommended but with a warning that it could make things worse and couldn't be reversed if that turned out to be the case. Before agreeing with the epiglottis trim, I asked for a second opinion from the senior Doctor at Emory Voice who after careful review indicated that he believed I was suffering from sensory neuropathy and the epiglottis trim was bad idea and that the previous tongue reduction probably was not of any use. Based on the sensory neuropathy diagnosed, I was prescribed Lyrica for several months which brought no improvement in systems.
After several months of unsuccessful Lyrica pills in conjunction with the fact that no matter ho hard I tried to swallow or wash down the residual material and I was now having to do a nightly 3 to 5 hours session (up from 1 to 2 hours) in a chair facing the tub forcing belches to force up the trapped residual material in my throat that refused to be swallowed so that my airway would be clear enough to allow me to sleep, I decided to give my original ENT another shot. I explained to him I was spending several hours a day burping in order to clear my airway and explained that I was often having to sleep in an upside position so that the residual material wouldn't drip into my airway during sleep. I pleaded for some sort of surgery on my lower throat but the ENT thought with all my belching and upside down sleeping I was half crazy and he refused to proceed with any treatment until I was on anti anxiety medication for at least 3 months. I asked him to write me a prescription and he indicated that treating anxiety is not part of his specialty and he referred me back to my primary care Doctor. Because I am on Adderall XR for adult ADD, I have to see my primary doctor monthly and on my next visit I asked him to put me on anxiety treatment in which he then explained that my antidepressant Cybalta is actually a antidepressant and anti-anxiety combo which I had already been taking for a couple of years.
I then returned to my ENT and explained I have already been doing anti-anxiety meds for 2 years so could we please proceed with the next step to fixing this swallow problem. He then disclosed that he see's nothing wrong with my throat and doesn't know what to else to do. I then told him that I've been told I snore and asked if it is possible I have obstructive sleep apnea of my lower throat which could also be causing these swallowing symptoms. He replied that I should have a sleep study. A sleep study was performed within a week and it revealed I was having between 65 to 200 AHI events per hour with oxygen saturation decreasing down to 83% and overall sleep efficiency of 79%. A couple months later MY ENT ordered a CPAP trial which later lead to me going on BiPAP treatment during sleep. I tried the BiPAP mask for 3 nights but it gave me major chest pains and seemed to want to blow the residual material in my throat down into my airway. I suspect that my shallow breathing brought on by the presence of pooled secretions at the top of my airway was triggering the BiPAP machine's "smart switch" to falsely assume I wasn't wearing the mask and would automatically shut down the machine causing me to re-breathe expelled air lingering in the 6' tube.
In between the two sleep studies,on one afternoon, earlier in the day than usual, I sensed a large accumulation of residual material in my throat and was able to get in to see my ENT within a couple of hours who looked down my throat with the fiber-optic scope and found "lots of crud" in each of my pyriform sinuses. I explained to him that "crud" was residual material left over from breakfast that I had eaten several hours before. I was so glad I was able to get my ENT to finally see for himself this residual material as he was under the assumption it was either reflux or was imagined.
Regardless of why the BiPAP wasn't working in conjunction with the confirmation of pooled secretions in my pyriforms, my ENT recommended UPPP and septoplasty to eliminate the obstruction causing the sleep apnea. I am now recovering from this combo surgery that was performed two weeks ago. The residual matter in my throat has become worse since the surgery and like I said before, the presence of this residual matter makes it hard for me to breathe which is a frustrating way to live, in that I'm always having to carefully inhale without sucking in the residual material into my windpipe.
I am desperate to resolve this matter. I have hit my maximum annual out of pocket limit on my BCBS insurance and I basically now have 100% insurance with no deductible.
Some additional general bullet point information is also provided below:
1) I have NOT had a Fiber-optic pharyngoscopy done while using continuous positive airway pressure (CPAP) to find the areas in my airway that collapse during sleep.
2) I have had a CT scan of my neck but not one of my sinuses done.
3) A cephalometric X-ray has not been performed.
4) After swallowing I am more likely to aspirate viscous liquids like water or soup broth than I am to aspirate thicker liquids.
5) I often cough up from my throat items that I have eaten several hours or even the day before.
6) If I eat a colored popcicle, I will for several hours (or even the next morning) be able to spit up or cough up from my throat saliva matching the bright color of the popcicle (even after drinking plenty of liquids and broushing my teeth and garling with mouth wash).
7) My ENT has indicated I do not have a Zincker's pouch.
I awake often during the night having to clear un-swallowable saliva and phlegm and spit it out on to the hand towel I sleep with.
9) I often have to burp after drinking or eating in order to "re-set" the top of my esophagus and bottom of my throat in order to be able to receive more liquids or solid foods.
10) After I have already sipped liquid or chewed food and worked the bolus to the back of my tongue, I suddenly realize my esophagus is not going to accept the bolus and I have to spit out whatever is in my mouth, do a "re-set" burp and then re-attempt the swallow.
11) I used to be able to close my mouth and do a downward suction snort to gather the residual material gathered in my throat which I could then spit out or swallow. This maneuver is no longer effective.
12) Chin tuck swallows do not help.
13) Head turned swallows will keep additional food particles from going into one pyriform sinus but does not prevent the other pyriform from retaining the newly swallowed material.
14) I purchased a suction machine off ebay in 2004 in hopes it would suction out the un-swallowable residual material in my lower throat. At first, this machine was useless as I could not get the suction tube low enough in my throat to be of any use. However, in the past year, the machine has become more useful to remove large quantities of frothy liquids in my lower throat but I am not able to get it to "get it all out" with the suction device.
15) I often have trouble swallowing my normal saliva so I have to spit often which is made worse when I experience excessive drooling which occurs when something is "stuck" in my throat.
16 I often feel the need to swallow, I want to swallow whatever's in but regardless of my inability to dislodge and swallow the retained material, I sometimes tongue pump and repeatedly swallow involuntarily.
17) I have not had a FEESST test done.
I am wondering if I might have a cricopharyngeal disorder and wondered if I might benefit from a cricopharyngeal myotomy.