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Posted by on in TNE
TransNasal Esophagoscopy (TNE)

TNE stands for TransNasal Esophagoscopy. It is a method of examining the esophagus, the structure that connects the throat to the stomach, without putting someone to sleep or giving any sedation. The traditional method of examining the esophagus was to  place a large round camera, think of a garden hose, through the mouth then into the esophagus and stomach. One has to be sedated with intravenous medication or medication in the vein, so that one doesn’t gag during the procedure. The gag reflex is actually located in the mouth. However, by going through the nose one bypasses the gag reflex. So by using an ultrathin camera, the size and texture of a cooked piece of spaghetti, the gag reflex can be bypassed, and the esophagus can then be examined without having to sedate or knock out the patient. It’s much safer for the patient as almost all the risks of upper endoscopy are not related to the procedure itself, but to the sedation administered during the procedure. So people should be aware that there are alternatives to traditional sedated endoscopy.

TNE is one-fifth the cost of traditional sedated endoscopy. TNE is performed not only by ENT doctors but by gastrointestinal doctors as well. To understand the potential positive impact of awake upper endoscopy or an unsedated exam of the food pipe, there are approximately 10 million upper endoscopies performed each year in the United States. The facility fee, that which the insurance companies, including medicare and medicaid, pay when the procedure is done under sedation, averages an extra $1000/ procedure. Or 10 Billion dollars a year. Conservatively, half of these procedure could be done with the patient awake, therefore saving us taxpayers 5 billion a year. Even more important is the greater patient safety when people don't need to undergo sedation. TNE is a medical advance exemplifying one of those rare situations where not only can the entire healthcare industry save money, but it is much safer for patients.

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RISKS OF SEDATION DURING UPPER ENDOSCOPY

Are there alternatives to sedation for those needing an upper endoscopy, or does everyone have to be sedated?

There are almost 10 million upper endoscopies performed annually in the USA. Upper endoscopy is the insertion of a camera through your mouth to look at your esophagus and stomach, generally done when someone has complaints of chronic heartburn. In general, one needs to be sedated with a twilight type of anesthesia during an upper endoscopy. However, conscious sedation is not necessarily a free ride. There are small but finite risks associated with conscious sedation, namely problems with the heart (heart attack) and lungs (stopping breathing) that can take place.

Most people are not aware that there are certain circumstances where sedation may not be necessary, especially when one only needs to examine the esophagus (the tube that connects the throat to the stomach). This procedure is called TransNasal Esophagoscopy(TNE), where an ultrathin camera, the size and softness of a piece of cooked spaghetti, is performed with the patient wide awake, in a doctor’s office, only requiring a small amount of numbing medicine misted into the nose.

The indications for a TNE are the following:
1. Chronic cough (8 weeks or more)
2. Hoarseness
3. Lump-like sensation in the throat
4. Frequent throat clearing
5. Difficulty swallowing

The contraindications to performing a TNE, i.e. TNE is not the right exam,
rather a sedated upper endoscopy is the more appropriate exam, are:

1. Abdominal pain
2. Nausea
3. History of ulcer disease

TNE: Myths and Facts
MYTH #1: TNE is not as well tolerated as conventional endoscopy (EGD). 

FACT: From 1996 until now, there have been numerous studies comparing TNE and EGD, demonstrating that patients can tolerate a camera in their nose as well as they tolerate a camera in their mouth.

MYTH #2: TNE is not as effective as EGD.

FACT: Unsedated TNE has demonstrated equal accuracy in the detection of Barrett esophagus when compared with conventional, sedated, transoral upper endoscopy.  

MYTH #3: TNE is expensive. 
FACT: TNE is one-fifth the cost of EGD.

MYTH #4: TNE will increase our national health care costs. 

FACT: TNE can save the health care industry about $5 billion per year.

MYTH #5: TNE has side effects. 

FACT: Beyond the potential for a nosebleed, TNE is exceedingly safe.

 

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Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST)

FEESST is an office-based, non-X-ray alternative procedure to traditional X-ray based tests of swallowing, such as an upper GI series. It is a non-invasive way of letting physicians know if numbness has occurred in the throat and also allows one to evaluate swallowing problems. FEESST is performed with an ultrathin camera that is placed through the nose to examine the throat. While the camera is in place, sensation of the throat tissues is determined by giving small puffs of air through the camera in order to elicit a vocal cord reflex, much like the air puff test given to test eye, or corneal, reflexes.  Once sensory level is determined, the patient is then given food which has green food coloring in it to see where the food goes in the throat. FEESST is primarily utilized in patients with stroke and chronic neurodegenerative diseases such as Parkinson’s, ALS (Amytotrophic Lateral Sclerosis or Lou Gehrig’s Disease), MS (Multiple Sclerosis), Myaesthenia Gravis, and the muscular dystrophies.

FEESST also allows one to demonstrate that acid injury from Throatburn Reflux (LPR) could cause enough swelling of the laryngeal tissues to result in numbness in the throat and esophagus. When a person’s throat is numb, they are likely to cough, choke, and aspirate. However, by treating the acid reflux problem, the numbness goes away, the tissues return to normal appearance, and often one’s swallowing problems begin to improve.

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Esophageal Cancer: The fastest growing cancer in America and Europe

The esophagus is a long flat muscular tube that connects the throat to the stomach. Before 1970, esophageal cancer (EC) was attributed predominantly to smoking cigarettes and alcohol abuse which resulted in a specific type of cancer known as squamous cell carcinoma. However, in the last forty years, a different type of esophageal cancer, known as adenocarcinoma, that due to acid reflux disease, has become predominant. 

The incidence of esophageal adenocarcinoma was just four cases per million in 1975. By 2008, it had grown to an unprecedented 26 cases per million. This represents a 650% increase in incidence, making esophageal cancer the fastest growing cancer in America and Europe. During this same time, nearly all other cancers (e.g. breast, colon, prostate) have remained flat or decreased in incidence 

Among the reasons for the dramatic shift from one type of esophageal cancer to another is the result of the coupling of two seemingly unrelated events, legislative intervention by our government and food industry changes.

a. Legislative intervention by our government- a little known Food and Drug Administration (FDA) law called Title 21, originating in the mid 1970’s, mandated that any food in a can or a bottle needs to be acidified to act as preservative to prevent food poisoning. The unintended consequence of Title 21 was that food items we all thought exceedingly safe, are now actually harmful. For example, take a tasty, healthy banana. The relative acidity of a banana is near neutral, however, baby banana food, in a bottle, is 100 hundred times more acidic than a whole banana. SO THE ACID INSINUATION INTO OUR LIFE BEGINS IN INFANCY!

b. Food Industry changes, specifically, the explosion of processed foods since the mid to late 1970’s. Not only do processed foods increase acidity, they are often themselves acidic.  For example, SUGAR, around 1980, went from the more expensive cane and beet sugar to the less expensive corn-based sugar, in particular HIGH FRUCTOSE CORN SYRUP (HFCS). What’s the problems with HFCS? First, it has sulfuric acid in it. To make matters worse, the chemicals used in the processing have the physiological effect of loosening the muscle that separates the stomach from its adjacent organ, the esophagus, called the lower esophageal sphincter (LES), which can allow stomach acid to rise unchecked into the esophagus and throat. 

Another example is SOFT DRINKS- in 1975 soft drinks surpassed coffee as America’s favorite beverage, and we never looked back.  Soft drinks are the most acidic substances we consume, similar to our car’s battery acid. One of the great ironies we see nightly on television shows that feature singing and talent hopefuls is that often the only “prop” the judges have on their otherwise bare tabletop is a cup of branded cola (they certainly don't have a bowl of carrots on their tabletops). So the substance that can injure vocal folds is widely advertised during shows about beautiful voices. It’s like having the tobacco companies sponsor the Olympics.

So the prevalence of processed foods in our diet in conjunction with the consequences of Title 21 has created the ideal climate for our current acid reflux epidemic setting in motion a perfect storm of conditions for the rapid growth of esophageal cancer.

Generally, most cases of esophageal cancer are detected too late, when the patient already experiences difficulty in swallowing because of a cancer blocking the esophagus.  At that point, the cancer will have already reached an advanced stage. Regrettably, the average five-year survival rate at this stage is only 10-15%. However, by becoming knowledgeable about non-typical acid reflux symptoms, such as chronic cough, hoarseness, frequent throat clearing and a lump-like sensation in the throat, you give yourself the opportunity to detect pre-cancerous changes in the esophageal lining before it may become cancer.

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Posted by on in Post Nasal Drip
Post Nasal Drip (PND)

Post nasal drip (PND) refers to the sensation of mucus or secretions coming down from the back of one’s nose into their throat. PND is classically seen in people with allergies and sinus disease, but it is also one of the most common symptoms of Throatburn reflux.

The body normally produces between 1-2 liters of mucus a day from the nose and sinuses. This fluid, typically unnoticed, is distributed over a 24 hour period and is generally swallowed without incident. However, if there is blockage in the nose, sinuses or throat, the “drip” sensation becomes noticeable and complaints invariably ensue.

The drip sensation occurs frequently in people with Throatburn reflux because the back portion of the larynx swells in response to constant acid exposure, either from acid coming up from the stomach or from activation of pepsin receptors in the throat directly from acidic foods (processed foods, sugary soda, citrus, tomato, vinegar) which in turn will cause swelling of throat tissues. 

The treatment of PND is directed towards relieving the areas of obstruction, In the case of a nose/sinus source of the drip, often a food and an environmental allergy investigation is warranted. Occasionally, an imaging study of the paranasal sinuses, either a CT scan or an MRI, is carried out so the anatomy of the nose and sinuses can be figured out.

In the situation where there is no significant nose and sinus disease, and there is swelling of the larynx, then treatment of acid reflux disease – diet, lifestyle and occasionally medications - should take place.

 

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I have a lump in my throat (globus sensation)

Globus is a Latin word for globe or sphere, which is what people often describe when they come in to see me complaining of a lump-like sensation in their throat.  It is one of the most common complaints I see on a daily basis and is a very uncomfortable and troubling symptom for patients because they often feel like something is always present in their throat, or something is stuck in their throat, especially when they are swallowing. While there is a known entity in the psychiatric scientific literature of something called “globus hystericus” (the implication being that the lump-like sensation is because of psychological issues), I believe that almost all “globus” complaints are not in someone’s head, but truly in someone’s throat.

The important thing to do when a complaint of globus presents itself is to figure out what’s causing the lump-like sensation which will then allow proper treatment to take place. The first step is the patient’s history. How long has the sensation been going on? A globus sensation that has been going on for several days often suggests either an infection or some type of allergic response. A globus sensation taking place for months suggests a more chronic process such as acid reflux disease, a nerve injury in the throat, or even a tumor. For example, if the lump-like sensation been getting worse and worse then a situation of worsening symptoms is always worrisome and underscores the importance of taking this symptom seriously. What circumstances, if any, were associated with the onset of the globus sensation? A globus sensation associated with eating certain foods or after a bad cold or flu, can further direct  the attention of your health care professional to the source of the problem. What makes it better? What makes it worse?

Diet and lifestyle history are also critical items to know. As far as diet, I always ask about 10 types of foods,  4 common acidic foods such as soda, citrus (lemon, lime, pineapple, orange, grapefruit), tomato and vinegar. Then about 6 common foods while not in and of themselves generally very acidic, but have effects on digestion that can cause problems for those who might have acid reflux disease, such as caffeine, chocolate, alcohol, mint, onion and garlic. Those 6 commonly consumed foods share the following trait, they all are powerful relaxers of the muscle that separates the stomach from the esophagus, called the lower esophageal sphincter (LES).  Caffeine, which is often in chocolate as well, has the additional property of increasing acid production by the stomach. So caffeine and chocolate can not only loosen the protective muscular barrier between the acidic stomach and its adjacent structure, the esophagus, it can also increase acid production by the stomach, a physiologic “one-two punch” that can create misery for people, as acid from the stomach can then freely travel up the esophagus towards the throat.

Lifestyle history is also key. Eating late at night then lying down to sleep, or lying down right after eating are very common risk factors for the development of globus type symptoms. Smoking any substance is important to know as well, as smoking directly irritates the throat and, depending on what you are smoking, nicotine for example, can also have physiologic effects that loosen the stomach–esophagus barrier. Further, and this is always my greatest concern when I see patients who smoke or have a past history of smoking, there is always the risk of cancer in the head and neck and esophagus when smoking is part of the mix.

So once a thorough history is established, it is then important to examine the patient to see what is going on in their throat that might be causing their globus complaint. Examining the neck to make sure there are no lumps or bumps is essential. Then examining the nose, mouth, back of the throat, tongue, gums and teeth takes place. Abnormalities in those areas may give a hint as to the cause of the lump-like sensation. For example, in someone who has a few days of a lump-like sensation and a red throat on exam, that points more to an infection as the cause. On the other hand, if a mass is seen in the tonsil or tongue area, then that points to a tumor as a possible cause. 

Generally, the most effective way to see what’s taking place in the throat itself is to use a tiny camera that is passed via the patients nose into their throat to actually visualize the throat structures in real time. This office-based procedure is called Transnasal Flexible Laryngoscopy (TFL) and allows the physician to see exactly what is going on in a patients throat, tongue, vocal fold area, top of the esophagus and top part of the windpipe. With TFL one can see if indeed there is swelling in the throat that's causing the lump-like sensation. Nerve injury, tumor, consequences of allergies can all be determined with this type of exam. By far the most common cause of a globus sensation is acid reflux from the stomach, called Throatburn reflux. Also known as LPR (LaryngoPharyngeal (Lah-ringo faren gee uhl) Reflux), sometimes called “silent” reflux or "airway" reflux. I am not fond of the term “silent” (meaning no heartburn) reflux because the symptoms of a lump-like sensation in the throat is rarely silent as my patients are often constantly clearing their throat and coughing to clear their throats of that lump-like sensation.

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Posted by on in Hoarseness
Hoarse voice, raspy voice

Hoarseness is defined as a raspy or strained voice which can be due to many causes. One of the most common causes of hoarseness is voice overuse, misuse or abuse. Generally people who use their voice a great deal often have voice problems, such as parents of young children, teachers, clergy, and professional singers, actors and performers.

However, in addition to length of time talking and the style of how one speaks, other factors may play a role in the development of voice issues, in particular acid reflux disease. Stomach acid can affect the voice in two different ways, either from acid reflux coming up from the stomach, or from acidic foods coming down from the mouth after being swallowed and then directly irritating the throat and vocal folds. The direct injury to the vocal fold is via “tissue bound pepsin” that gets activated in acidic environments, such as when drinking sugary sodas, eating processed foods, citrus fruits (pineapple, orange, grapefruit, lemon, lime), vinegar, and tomato.

The vocal folds can also be directly irritated from noxious, carcinogenic substances like cigarette or cigar smoke.

Another cause of hoarseness may be some type of bump or tumor on the vocal fold itself, or even from a vocal fold that is not moving well, for example a paralyzed vocal fold.

To properly treat the hoarseness requires an accurate diagnosis of why the individual is hoarse. The best way to make an accurate diagnosis is to have a look at the vocal folds in action via tests ear, nose and throat (ENT) doctors perform, called Transnasal Flexible Laryngoscopy (TFL) or Laryngeal Videostroboscopy. Each test uses some type of ultra-thin flexible or rigid camera to look at the vocal folds moving in real time with the patient wide awake. 

Once the cause of the hoarseness is determined then treatment is tailored to the source of the problem. Very commonly, acid reflux disease, generally the Throatburn reflux type, also know as LaryngoPharyngeal Reflux (LPR) or “silent“ reflux, can either cause, or contribute to, the hoarseness as a result of the vocal folds being swollen by acid injury. The treatment is typically multifaceted, often including a form of physical therapy called Speech Therapy, in addition to dietary and medical therapies. Dietary treatment requires low acid diets, along with certain lifestyle changes such as avoiding late night eating and staying up for at least 3 hours after one’s last meal.  

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Posted by on in Chronic Cough
Chronic cough

Chronic cough, defined as cough lasting for more than 8 weeks, is the most common reason patients see a doctor in the United States. It is responsible for 28 million patient visits per year, more than twice the incidence of the next most common complaint, headache. It is one of the most misdiagnosed symptoms in medicine.

While chronic cough is one of the classic symptoms of Throatburn Reflux, in order to determine the precise source of one’s cough there is a very basic algorithm that one should follow.

When you have a chronic cough, the first thing you should do is stop smoking. Next, check your medications, as some medications themselves can cause cough. Then, problems with the lungs, allergies, nose, and sinuses should be ruled out as the source. If ruled out, turn attention to your throat where an ear, nose and throat (ENT) exam is performed using an ultra-thin camera, the size and softness of a cooked piece of spaghetti, called Transnasal Flexible Laryngoscopy (TFL). The most common cause of unexplained cough is acid reflux disease, specifically Throatburn Reflux (or LaryngoPharyngeal Reflux (LPR), also sometimes called “silent” reflux or “airway" reflux).

If signs of acid reflux are seen, a low acid, high fiber, nutritionally balanced diet such as the Acid Watcher® Diet and medical treatment is used. Also, because of the chronic cough, a TransNasal Esophagoscopy (TNE) should be performed to make sure no pre-cancerous conditions exist in the esophagus.

After acid reflux is considered and ruled out, you must then consider either nerve injury to the vocal cords, or a tumor on the vocal cords, or even vocal cord dysfunction (VCD, also known as paradoxical vocal fold movement disorder (PVFMD)) as the source of the cough.  If a nerve injury such as a vocal fold paralysis is seen, then imaging such as an MRI of the neck is performed to make sure there is no tumor pressing on the nerve in the neck that moves the vocal fold. If a tumor is seen on the vocal fold during the exam of the throat, then a biopsy of the tumor should take place. Finally, if VCD is seen, which is a vocal fold movement pattern where the vocal folds start to close during quiet breathing, as opposed to the normal circumstance where they essentially stay open during quiet breathing, then appropriate treatment should commence.

 

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