Yet One More Question From Dr. Park

[Steven Y Park, MD]

How many of you have any or all of the following:

Chronic cough,
Hoarseness
post-nasal drip,
mucous
throat clearing
lump sensation
tightening
throat pain
difficulty swallowing
or burning?

[opie74]

Thank you for your time and concern.  it is rare to find a doc as kind and thurough as you have been!

[Mand125]

None of the above

Mand

[fortywhat2]

I have it all!!!
Debbie
~live as if all your dreams came true~

[Steven Y Park, MD]

Believe it or not, I hear about what you describe occasionally from my patients too.

[Udkas]

Hi,
Thanks for providing such an interesting thread/info to the MS forum that is obviously relevant to so many people on this forum. Your questions and the answers are certainly interesting and I am sure everyone on this forum has benefited from your input.

I am pleased to report, I sleep better than a baby, none of my babies ever slept, (sleeping babies must be a myth), no reflux, no swallowing problems etc. and no snoring, no cough, but I do not have a diagnosis either.

Cheers,
Udkas.

[Sarahsmom46]

I've been reading this thread and a question I've been wanting to ask you that is somewhat related, occurred to me.  It also is a little strange I know, but I gotta ask.

Have you ever had a patient mention that they were dreaming about having breathing problems just before they suddenly awoke to "breathing problems"?  This has happened to me so many times that I know its not just a coincidence anymore. I thought that maybe its my bodies way of waking me up when from apnea or lung issue (acid reflux in the lungs) by integrating my physical symptoms in to my dream.  Strange eh?

-Julie

[Steven Y Park, MD]

If your father snore that badly, he probably has obstructive sleep apnea. This can aggravate reflux into the throat. Even your own bowel migraines could be attributed to a sleep-breathing problem, since you're your father's son.

[opie74]

My gaterso speculates that I have been having Migrane pain in my assending colon.  There is no other explination that he can find.  I obviously have some motility problems in that area.

My father had reflux so bad that he had the valve on the top of his stomach rebuilt as he says.  Now he absolutely can not vomit!  But, the reflux is improved.  He is a  radicle snore machine!

[Steven Y Park, MD]

Laura,

I believe Nutcracker esophagus is a motility problem due to spasming and  poor coordination of contractions, and this is different from achalasia, where you have damage of the nerve bundles that supply the esophagus. I think we have to consider these conditions separate from LPRD, but it's possible to have both. Sometimes it's really hard to tell the difference just based on symptoms and without any testing.

Barrett's is a condition where chronic acid regurgitation into the lower esophagus irritates the lining and causes pre-cancerous lesions. Yes, acid reflux medications and dietary changes do help, but these treatments don't address why acid comes up in the first place. It's speculation on my part, but I have a "gut" feeling that the sleep-breathing problem that I describe may be involved.

One other thing to consider which takes us back to the migraine theory is that you can in theory have migraines in any part of your body. This is what Dr. Buchholz (the Hopkins neurologist that I interviewed recently) postulates, and I agree with him. Whenever nerve endings go haywire and are overstimulated by certain "triggers", you'll get specific symptoms depending on where this process is happening. If it happens in the sinuses, you get sinus headaches, pain, pressure, post-nasal drip and a stuffy nose. If it happens in your jaw muscles, TMJ. If if happens in your stomach, bloating, diarrhea or constipation.


ShadowSidter,

You're absolutely right. What I'm describing should not be taken as information in place of the standard MS explanations, just in addition to it. This is such a common thing that's seen in other chronic conditions as well.

[ShadowsSister]

So much to read, so little time.
As I stated earlier my problem was related to the MS. The trachea Tube has been a life saver for me, but I also realize not every one has spasms as bad as I do, and I would not recommend this for anyone. That's the thing about MS no two cases are alike, we are all very different.
My fear is that there might be someone who is having spasms like the ones I have in my throat area and it will be overlooked and they will be treated for "LPRD", and the connection to MS will be over looked.
Thank you for your time and all the information you are sharing with us.

[saveone]

Today I have undergone esophageal motility testing and tomorrow is the videoscoping.   We all undergo so much looking for answers.  I have to say you have provided more info than most.  Thank you.

terry

[sllowe]

Thank you so much. You've explained this so well, and I'm so very grateful.  Not to self diagnosis, but I fit the symptoms to a T. I never feel anything from the stomach, and the "stuff" I get up everyday is clear, think and 'feels' like it's from my lungs - but maybe it's not. I need to make time to stop in your forum.

Thank you again,
Shell
  

[Lulu54]

Could LPRD be misdiagnosed as Nutcracker esophagus or is that part of the constrictive action- a lot of us have heard that one! And a whole bunch of us have undergone esophogeal motility tests and videoscoping.

How about Barrett's - although that is confirmed by a pathology report, could stage one also be a misdiagnosis?

Why don't all doctors explain this stuff to their patients instead of giving a one sentence diagnosis if we're lucky and then dismissing us with a pat on the head?  sorry, I know you can't answer that one but we're not feeling so friendly toward doctors here today.  

[Steven Y Park, MD]

Laryngopharyngeal reflux disease, or LPRD is probably one of the most common conditions that ENTs see, but treated in isolation, results are less than ideal. The textbook explanation is that it's a dysfunction of the upper esophageal sphincter so acid leaks up into the larynx, causing inflammation and all the other throat symptoms that I listed above. LPRD is different from GERD in that you don't have to feel anything in the stomach.

The standard recommended course of treatment is TWICE daily of any of the proton pump inhibitors (Prilosec, Aciphex, Nexium, Prevacid, Protonix, etc.) to be taken BEFORE breakfast and dinner. Once daily is not good enough. It also has to be taken for a long time. Our academy recommends months. You also have to address the typical dietary changes such as not eating before bedtime, avoiding alcohol before bedtime (within 3-4 hours for both), avoiding spicy or citrusy foods, etc. It's similar to the GERD diet. Not eating late before bedtime is probably the single most important thing that you can do (alcohol is #2), even more important than the medication.

This regimen works most of the time to various degrees, but the symptoms usually come back weeks, months, or years later. There are a few problems with this approach: although you're lowering the acidity of your stomach juices, it's still somewhat acidic. Your stomach contents also include bile, digestive enzymes and bacteria. Microscopic amounts of these substances can wreak havoc on your very delicate voice box structures. These materials have also been shown to reach the lungs, ears, and sinuses. This can cause inflammation in these areas which can present as your typical "infections."

The other reason for the lump sensation and the tightening that many people feel in their throats is probably due to spasming of the cricopharyngeus muscle. This is part of the upper esophageal sphincter and is the muscle that wraps around the esophagus behind the voice box. When irritated or if aggravated by other stress factors that can cause muscle spasm, you can get the classic "lump" sensation with difficulty swallowing, or a tightening sensation.

So who do these juices come up to the throat in the first place? As I more fully describe in my book, many people have jaw narrowing and dental crowding that predisposes the tongue to fall back more when lying flat. Then during deep sleep along with muscle relaxation, the tongue falls back completely and begin to obstruct. Most people wake up very quickly (less than a few seconds) so it's not an apnea. People with these issues know not to sleep on their backs. The problem is that despite sleeping on their sides of stomachs, it's not good enough. When you obstruct, but before you wake up and turn over, a tremendous vacuum effect is created in the chest and throat which suctions up microscopic amounts of stomach juices into your throat. Sometimes you'll be fine until you get a simple cold or an allergy attack and a vicious cycle happens, where due to swelling, the tongue falls back easier and more juices are brought up, causing more inflammation. When the inflammation spreads to your nose, this makes your nose more congested, causing more of a vacuum effect downstream, causing your tongue to collapse even easier.

This is why taking an acid reflux medicine doesn't help consistently (since it does nothing for the reflux—it only lower the acid content). When it does work, it probably works by promoting less irritation and inflammation of the throat.

Furthermore, since your upper molars are more narrow, the side walls of your nasal cavity is more narrow, since the side walls follow the upper jaw. So if there's any inflammation in the nose, it gets stuffy faster. Also since the angle between your septum and your nostril is more narrow, your nostrils will cave in more during inspiration.

So the overall effect is that if you have this condition (UARS), you'll never feel refreshed in the morning because you're unable to get any deep sleep. This can create a physiologic stress response that can wreak havoc on your nervous system (makes it hypersensitive), your immune system (also makes it more hypersensitive), and affects almost every hormone in your body.

I also see what can be described as "migraine" attacks in various parts of the body. But we can talk about that another time.

[Lulu54]

Dr. Park,
I did order your book and it arrived today - in the very first chapter you have given me an explanation of why I have this choking happen where I literally can't breathe.  LPRD fits me to a tee and like Shell I now want to know how its treated. I sure hope its in the book.    My GI doc decided it was anxiety that was causing me to choke.  Thank you, thank you, thank you for making this problem clear.  Perhaps I will give him your book after I am done reading it!

Laura

[sllowe]

Dr. Park,

Thank you once again.  So what is the treatment for laryngopharyngeal reflux -  and does the cause matter? How is it dx'd? I'm sorry if this question belongs in your forum.  Just wondering if there would be a different course when and if it's found to be MS related.  

I did not have the problems I have now pre-MS.

This thread is incredibly educational....
-Shell

[hbananas]

Me, the TM lady..
I have been told I have hiatal hernia, and I have reflux.  Hardly ever happens anymore, since I don't eat late at night, and gave up alcohol.  I did have a little "burf" (cross between burping and barfing) the other night, first time since starting CPAP.  Kinda scary, wondering if you're going to pollute your mask.

Chronic cough-, Have had, not for a few years.  Esp when I was on an ACE inhibitor.
Hoarseness- no
post-nasal drip-, Always a little something trickling back there
mucous -Not much since severe allergies successfully treated
throat clearing- ditto.  I sort of learned not to do it because it irritates my husband, and because I sing and the director says it's bad for the voice--swallow a lot and drink water instead.
lump sensation- Yes.  Sometimes I get esophagus spasms, if I eat too quickly, then even drinking a lot of water doesn't get it totally relaxed.
tightening -ditto
throat pain -ditto.  Kind of mid-chest
difficulty swallowing -sometimes
or burning? When there is reflux.  Chocolate is a big contributor.

[Steven Y Park, MD]

Thanks for the information and sharing your story.

A thought just came up for another question....

[Quixotic1]

Someone a while ago told us about a study showing that a huge number of patients with MS meet the definition of sleep apnea and that 50% of them were obstructive.  So both types are seen in MS.  I'll see if I can rustle up that study.

With regard to what you would expect, I suggest that, while there would be plenty of reason to have central apnea, the muscular effects of MS can lead to an obstructive pattern in several ways.  We have upper airway and chest spasms which are often tonic and sustained.  We also have loss of motor function seen as weakness or flaccidity.  Both of these processes are seen in the breathing and swallowing symptoms we report.

On a more personal note, I have an extraordinarily small jaw due to congenital deficiency of 13 permanent teeth.  They have to use a pediatric tray to get impressions.  My TMJ lost all it's cartilage by the time I was mid-30's, and is permanently subluxed.  My jaw excursion is about 25mm.  I wonder what kind of sleep I would have if I slept lying down instead of propped up so far. (I'm the one sleeping 12-14 hours a day in about 5 hitches.)

Again, I thank you for a fascinating new look at one of our worst problems - fatigue and cognitive difficulty.

Quix

[Steven Y Park, MD]

Before I answer your questions and spill the beans, I think it's safe to say the most of the people who gave answers on this post has a majority of the symptoms that I asked about. These symptoms are the classic findings in laryngopharyngeal reflux disease. This is when acid comes up into the pharynx, causing inflammation and irritation, leading to some or all of the above symptoms. It's thought to be due to a dysfunction of the upper esophageal sphincter, as opposed to a dysfunction of the lower esophageal sphincter that's seen in GERD.

The problem is that you only need microscopic amounts of stomach juices in your throat to cause these symptoms. For the double-probe pH studies, there's a certain number of reflux episodes at a certain pH to meet the criteria for LPRD. Using esophageal manometry, UARS patients (see next paragraph) have been shown to have significant negative pressure in the chest during an episode. You also have to realize that it's not only acid coming up, but sometimes bile, digestive enzymes and even bacteria. Studies have shown finding H. pylori and pepsin in middle ear, sinus and lung washings.

Upper airway resistance syndrome (UARS) is a variation/precursor to obstructive sleep apnea (OSA), where you don't officially meet the criteria for obstructive sleep apnea. You need at least 5 apneas or hypopneas every hour on average to say you have sleep apnea. Each episode has to last at least 10 seconds. But it you stop breathing 25 times every hour and wake up after 1-9 seconds, then your total score is 0.

UARS patients have a typical upper airway anatomy, where due to smaller jaw structures (with dental crowding) the tongue naturally sits higher and further back. Normally when on their backs, the tongue falls back somewhat due to gravity. But in UARS patients, there isn't too much space, so there's very little space behind the tongue. When in deep sleep, due to muscle relaxation, you stop breathing and wake up quickly, then turn over. Most people with UARS learn to sleep only on their sides or stomachs.

Dr. Guilleminault, a pioneer in sleep medicine that first described UARS, stated that OSA patients have underactive nervous systems, whereas UARS patients have a normal or hyperactive nervous systems (that's why they wake up too quickly into light sleep). As I've mentioned before, chronic long-term deep sleep deprivation can lead to a low-grade physiologic stress response. This can heighten not only your nervous system, but your immune system as well. Robert Sapolsky, in his very interesting book, Why Zebras Don't get Ulcers, makes the suggestion that repeated low-grade stresses ratchet up your immune system so that it stays hyperactivated for too long. This is in contrast to one big stress that ends, and the initially heightened immune system then drops to below normal, and then back to baseline. This is why many people get sick AFTER a very stressful event.


To be honest, before I started to participate on the MS forum, my understanding of MS was identical to yours. When Laura (LGK54) posted a question about sleep and MS, I was fascinated by what she had to say about the high incidence of sleep problems and the fact that a number of the members were on CPAP for sleep apnea. As I started reading through the MS forum, many of the symptoms sounded remarkably like what I seen in my patients with upper airway resistance syndrome. Symptoms include chronic fatigue, unrefreshing sleep, not being able to sleep on their backs, various cysts and nodules throughout the body, cold hands and feet, various GI issues, GERD, LPRD, depression or anxiety, hypothyroidism, low blood pressure when younger (and later on sometimes turning into high blood pressure), headaches, migraines, sinus problems, TMJ, lightheadedness, and one parent that snores heavily.

Many patients with UARS progress later on in life to obstructive sleep apnea, especially if they gain weight. Many people with UARS have a parent that has OSA.

Frankly, I was very surprised to see that the vast majority of respondents had each of the three other questions that I asked (sleep position, cold extremities, parental snoring, and now laryngopharyngeal reflux disease). Maybe it's more due to selection—only people with these conditions are replying.

Here are my conclusions about MS and UARS:

1. The similarities in symptoms are total coincidence and to be taken with a grain of salt, or
2. There is a link or a connection, but there may be a common point of branching higher up in the "cascade," or
3. both conditions have symptoms that overlap, although they are from two different origins, or
4. one may directly or indirectly cause or aggravate the other.

I think it's a toss up amongst all four options. One thing I'm much more appreciative of now is how prevalent sleep issues are in patients with MS (thanks, Laura). With the incidence of OSA to be up to 24% in men and 11% in women, and much higher if you include UARS, it may be worthwhile to at least screen for it anyway, even if you don't have MS. So what I'm seeing may be the natural incidence of sleep-breathing issues in the normal population (who just also happen to have MS).

I think the next step for me is to examine the upper airway anatomy to see if MS patients have the typical appearance that I see in UARS: the voice box and the tongue collapses severely when lying on the back, restricting the upper airway breathing passageways.

I'm in no way suggesting that MS is caused by a sleep-breathing disorder. I'm just very fascinated by the similarities between the two, and so I think it's worthwhile investigating it a little further.

Quixotic1,

You have some great questions. I have some very speculative thoughts on this, but I don't think this is good time or place to address them, unless I have more data or evidence to back it up. One thing about MS and breathing is that you would think breathing problems would be more of a central component, since the lesions are in the brain. I'm not sure if people with both MS and OSA have more obstructive or central.

[Karen99]

Occasional hoarseness only.  

[HVAC]

post-nasal drip,
mucous
throat clearing
lump sensation
tightening
throat pain
difficulty swallowing
or burning?

[doublevision1]

* occasional hoarseness

* occasional difficulty swallowing: food is slower going down and sometimes feels stuck; also, I can acutely feel food and liquid as it moves down my throat, like how ice water feels going down on a hot day.  Don't know if that makes any sense!

[Lulu54]

DJ, thanks for sharing that info with everyone here.  I often wonder how often this tendency toward spasm develops into something much more serious, or life-threatening in your case.  

Lulu