I?ve gathered a list of possibilities, but as you know, we can?t
diagnose online. Your doctors sound right on track, by looking at the
tests you have had. Remember tests are not infallible and sometimes
further testing is necessary. You don?t indicate if your nasal
passages/sinuses were cultured, of if you were checked for nasal
polyps. I would consider revisiting some of the diagnostic tests and
also look to reconsidering the diagnosis. Keep in mind that all
symptoms do not appear as described in all patients. Each case is
different, depending on age and general medical history.
Some of the information I?ve included, you have already ruled out.
Mind you, what has been ruled out appears to be the most likely causes
however. I?ve come up with some several other possibilities. Beyond
what I have found, I?d have to suggest further testing.
Please read each site posted for further information.
?Abstract A prospective radiologic-endoscopic study of the
esophagogastric region in 266 patients, including 206 normals and 60
with esophagitis, is reported. The endoscopic classification grading
severity of esophagitis was grade 1 ? normal; grades 2, 3, and 4 ?
mild, moderate, and severe esophagitis, respectively. Radiology
detected 22% of patients with mild esophagitis, 83% with moderate
esophagitis, and 95% with severe esophagitis. Although hiatal hernia
was present in 40% of normals and 89% with esophagitis, absence of
radiographic hiatal hernia excluded esophagitis with 95% accuracy. The
implications of this study regarding the role of radiology in
evaluating patients with suspected reflux esophagitis are discussed.?
?Like "achalasia," "hiatus hernia" is an example of a wrong name
paralyzing thinking about a disorder. Because they are called hernias,
"hiatal hernias" are lumped in with inguinal, femoral and ventral
hernias. We tend to assume that our instructors gave us the correct
names for things!
Standard references do not even discuss their pathogenesis. It is
simply taken for granted. After reviewing 636 references,
Postlethwait(7) concludes they are due to increased intra-abdominal
pressure in combination with weakness of the supporting structures.(8)
Even a group(9) that reported experimental production of hiatus hernia
by vagal stimulation concluded that most were due to increased
intra-abdominal pressure. A recent review(10) lists 17 possible
causes, except for increased intra-abdominal pressure, most of them
The central problem of "hiatus hernias" (HH), therefore, is to prove
that they are not hernias. Instead, I must show that the condition is
a traction phenomenon - that the fundus is drawn above the diaphragm
by the tractive force of longitudinal muscle contraction (LMC).?
Generic Name: fluticasone and salmeterol (floo TIK a sone, sal ME te rol)
?Fluticasone is a steroid. It prevents the release of substances in
the body that cause inflammation. Salmeterol is a bronchodilator. It
works by relaxing muscles in the airways to improve breathing.?
ADVAIR is available only by prescription and it is available in three strengths:
? ADVAIR 100/50
? ADVAIR 250/50
? ADVAIR 500/50
Do you take any of the following drugs?:
? ?amiodarone (Cordarone);
? a diuretic or "water pill";
? HIV medicines such as ritonavir (Norvir), indinavir (Crixivan),
lopinavir/ritonavir (Kaletra), nelfinavir (Viracept);
? an MAO inhibitor such as isocarboxazid (Marplan), tranylcypromine
(Parnate), phenelzine (Nardil), rasagiline (Azilect), or selegiline
? antidepressants such as amitriptyline (Elavil), nortriptyline
(Pamelor), desipramine (Norpramin), or imipramine (Tofranil);
? certain antibiotics such as ketoconazole (Nizoral), itraconazole
(Sporanox), clarithromycin (Biaxin), erythromycin (E-Mycin, Ery-Tab,
? medicines for depression such as fluoxetine (Prozac), or fluvoxamine (Luvox).
If you are using any of these drugs, you may not be able to use
Advair, or you may need dosage adjustments or special tests during
?During periods of stress or a severe asthma attack, patients who
have been withdrawn from systemic corticosteroids should be instructed
to resume oral corticosteroids (in large doses) immediately and to
contact their physicians for further instruction. These patients
should also be instructed to carry a warning card indicating that they
may need supplementary systemic corticosteroids during periods of
stress or a severe asthma attack.?
?Upper airway symptoms. Symptoms of laryngeal spasm, irritation, or
swelling, such as stridor and choking, have been reported in patients
receiving fluticasone propionate and salmeterol, components of ADVAIR
?Discontinuation of systemic corticosteroids. Transfer of patients
from systemic corticosteroid therapy to ADVAIR HFA may unmask
conditions previously suppressed by the systemic corticosteroid
therapy, e.g., rhinitis, conjunctivitis, eczema, arthritis, and
More on this further down in my answer: ?Eosinophilic Conditions: In
rare cases, patients on inhaled fluticasone propionate, a component of
ADVAIR HFA, may present with systemic eosinophilic conditions, with
some patients presenting with clinical features of vasculitis
consistent with Churg-Strauss syndrome, a condition that is often
treated with systemic corticosteroid therapy. These events usually,
but not always, have been associated with the reduction and/or
withdrawal of oral corticosteroid therapy following the introduction
of fluticasone propionate. Cases of serious eosinophilic conditions
have also been reported with other inhaled corticosteroids in this
clinical setting. Physicians should be alert to eosinophilia,
vasculitic rash, worsening pulmonary symptoms, cardiac complications,
and/or neuropathy presenting in their patients. A causal relationship
between fluticasone propionate and these underlying conditions has not
?Some side effects of Advair include: ?Hoarseness (dysphonia),
throat irritation, headache, cough, dry mouth or throat may occur.?
Side effects of Advair
? ?Eosinophilic conditions?Fluticasone may make these conditions worse.
? Osteoporosis (bone disease)?Inhaled corticosteroids in high doses
may make this condition worse.
Side effects of Advair - ?Less common:
? Abdominal or stomach pain; cough producing mucus; flu-like
symptoms; irritation or inflammation of eye; muscle pain; pain or
tenderness around eyes and cheekbones; sleep disorders; stuffy nose;
tremors; white patches in the mouth or throat or on the tongue
?There is also some concern that the more potent agents,
particularly fluticasone, suppress the adrenal system (which secretes
natural steroids) to a greater degree than other steroid inhalants.
(This is a serious side effect of oral steroids.)?
While Candida (yeast, thrush) is the most usual fungal infection
from steroids, it is not the only one. If you were cultured for
candida only, it?s possible you have aspergillosis, or some other
fungal infection. It?s possible to have a viral infection, not likely
to be cultured (expensive and performed by fewer labs), and it might
be a missed bacterial infection. Were your nasal sinuses cultured
?Side effects may include:
Bronchitis, cough, diarrhea, difficulty speaking, fungal infection of
the mouth, gastrointestinal discomfort and pain, headaches,
hoarseness, muscle pain, nausea, sinus problems, sore throat, upper
respiratory infection or inflammation, vomiting?
Photos: ?Left: Patient with hoarseness (treated extensively with
anti-reflux medication) who was using an Advair inhaler. The left cord
is swollen with a white patch on it.
Right: After 30 days treatment with fluconazole and stopping the
steroid inhaler the voice and vocal cords have returned to normal.?
?A more extensive fungal infection from a steroid inhaler. Candida is
the most common organism.?
?Examples of disease-causing organisms that may be found during a
throat culture include:
? Candida albicans. This fungus causes thrush, an infection of the
mouth and tongue and sometimes of the throat. See an illustration of
thrush in the mouth .
? Neisseria meningitidis. This bacteria can cause meningitis.
? Group A streptococcus. This bacteria can cause strep throat, scarlet
fever, and rheumatic fever. If strep throat is suspected, a test
called a rapid strep test (or quick strep) may be done before doing a
throat culture. With a rapid strep test, results are received in less
than 10 minutes (instead of 1 to 2 days with a throat culture). If the
rapid strep test results are positive, antibiotics can be started
immediately. A throat culture is more accurate than the rapid strep
The rapid strep test can give false-negative results even when strep
bacteria are present. When the results of a rapid strep test are
negative, many health professionals recommend doing a throat culture
to confirm that strep throat is not present.?
I?d have a second look at GERD and the possibility of a fungal
infection of the throat. It can be difficult to get a good sample for
fungal culture, and the first swab may have been mishandled. Your
symptoms certainly sound like a fungal infection. Acid reflux also can
cause your symptoms. Even with Prilosec, acid can still reflux and
cause burn and scar tissue.
?What are the symptoms of GERD? - The main symptoms are persistent
heartburn and acid regurgitation. Some people have GERD without
heartburn. Instead, they experience pain in the chest, hoarseness in
the morning, or trouble swallowing. You may feel like you have food
stuck in your throat or like you are choking or your throat is tight.
GERD can also cause a dry cough and bad breath.?
How GERD is diagnosed:
Eosinophilic Conditions (Allergies)
?Postnasal drip ? Postnasal drip is a condition that develops when
secretions from the nose chronically drip into the back of the throat.
These secretions can cause throat inflammation and trigger a cough.
Underlying causes of postnasal drip include allergies, colds, and
sinusitis. In addition, some people have chronic inflammation of the
nasal passages and a runny nose, which can also cause postnasal drip.
People with postnasal drip may complain of symptoms including stuffy
or runny nose, a sensation of liquid in the back of the throat, or
frequently having to clear their throat. However, some people have
so-called "silent" postnasal drip; they have postnasal drip but do not
realize it. A healthcare provider may suspect postnasal drip in a
person with a chronic cough based on the appearance of the patient's
throat. Postnasal drip is usually treated in a patient with chronic
cough when no other apparent cause is present.
Asthma ? Asthma is the second most frequent cause of chronic cough in
adults, and is the leading cause in children. Coughing may be
accompanied by wheezing and shortness of breath. However, some people
have a condition known as cough variant asthma, in which cough is the
only symptom of asthma. (See "Patient information: Overview of
Asthma is suspected as the cause of the cough if a person has a
history of multiple allergies or has a family history of asthma.
Asthma-related cough may be seasonal, may follow an upper respiratory
infection, or may get worse on exposure to cold, dry air, or certain
fumes or fragrances.
Gastroesophageal reflux disease ? Gastroesophageal reflux disease, or
GERD, develops when acid from the stomach flows back (refluxes) into
the tube connecting the stomach and the throat (the esophagus). The
presence of this acidic material in the esophagus, throat, or even the
lungs can lead to chronic irritation and coughing. (See "Patient
information: Gastroesophageal reflux disease").
GERD is the third most common cause of chronic cough. Many patients
with cough due to GERD complain of heartburn or a sour taste in the
mouth. However, these symptoms are absent in more than 40 percent of
patients with cough due to reflux.?
?Use of ACE inhibitors ? Medications known as angiotensin
converting enzyme (ACE) inhibitors cause a chronic cough in up to 20
percent of patients who take them. ACE inhibitors are used in the
treatment of heart disease, high blood pressure, and kidney disease.
The reason these medicines cause cough is not entirely clear, but may
be related to chemical changes that lead to stimulation of cough
receptors in the airways.?
Sinusitis and Post Nasal Drip
?Post nasal drip is an unscientific term that refers to the
sensation of thick phlegm in the throat, which can become infected. It
is annoying because normally the throat is moistened by the nasal
secretions and throat mucous glands. This is part of the mucous -
nasal cilia system that defends us from disease. When the amount of
liquid secreted by the nose and sinus is reduced, and the cilia of the
nose and sinus slow down, the fluid thickens and you become aware of
its presence. Since the thick phlegm associated with post nasal drip
is unpleasant and often infected because it is "just laying there" and
not moving, our bodies naturally try to get rid of it, to the
annoyance of our partners. Whether post nasal drip is caused by
pollution, chemical exposure, or severe infection, the treatment
requires that the cilia mucous system be brought back to normal.?
?Sore throat is a symptom of many medical disorders. Infections
cause the majority of sore throats and are contagious. Infections are
caused either by viruses such as the flu, the common cold,
mononucleosis, or by bacteria such as strep, mycoplasma, or
hemophilus.While bacteria respond to antibiotic treatment, viruses do
?Allergy: The same pollens and molds that irritate the nose when they
are inhaled also may irritate the throat. Cat and dog danders and
house dust are common causes of sore throats for people with allergies
Irritation: During the cold winter months, dry heat may create a
recurring, mild sore throat with a parched feeling, especially in the
mornings. This often responds to humidification of bedroom air and
increased liquid intake. Patients with a chronic stuffy nose, causing
mouth breathing, also suffer with a dry throat. They need examination
and treatment of the nose. Pollutants and chemicals in the air can
irritate the nose and throat, but the most common air pollutant is
tobacco smoke. Other irritants include smokeless tobacco, alcoholic
beverages, and spicy foods. A person who strains his or her voice
(yelling at a sports event, for example) gets a sore throat not only
from muscle strain but also from the rough treatment of his or her
?The major causes of rhinitis/sinusitis are viral infection,
bacterial infection, allergy, and blockage [from various causes] of
natural openings between the nose and sinuses. As a pulmonary
specialist, I see many patients referred for chronic cough, and the
vast majority have rhinitis/sinusitis with post nasal drip as the
cause. Most referred patients with chronic cough do not have asthma or
any lung disease as a cause.
Unfortunately there is much confusion and disagreement among
physicians about diagnosis and treatment of upper airway inflammation.
Confusion is mainly about diagnosis, disagreement mainly about
treatment. This web site is devoted to clarifying these issues as much
as possible, and to helping patients with chronic cough get proper
?Viral infection is a major cause of asthma, so viral rhinitis may
be a prelude to asthma attacks in susceptible patients (mainly people
who already have a history of asthma). Asthma can also develop
following viral rhinitis. Finally, some patients suffering primarily
from asthma also have concomitant rhinosinusitis.? ?Asthma can also
develop following sinusitis?.
?The following conditions are associated with multiple benign polyps:
? Bronchial asthma - In 20-50% of patients with polyps
? CF - Polyps in 6-48% of patients with CF
? Allergic rhinitis
? AFS - Polyps in 85% of patients with AFS
? Chronic rhinosinusitis
? Primary ciliary dyskinesia
? Aspirin intolerance - In 8-26% of patients with polyps
? Alcohol intolerance - In 50% of patients with nasal polyps
? Churg-Strauss syndrome - Nasal polyps in 50% of patients with
? Young syndrome (ie, chronic sinusitis, nasal polyposis, azoospermia)
? Nonallergic rhinitis with eosinophilia syndrome (NARES) - Nasal
polyps in 20% of patients with NARES
Most studies suggest that polyps are associated more strongly with
nonallergic disease than with allergic disease. Statistically, nasal
polyps are more common in patients with nonallergic asthma (13%) than
with allergic asthma (5%), and only 0.5% of 3000 atopic individuals
have nasal polyps.
Several theories have been postulated to explain the pathogenesis of
nasal polyps, although none seems to account fully for all the known
facts. Some researchers believe that polyps are an exvagination of the
normal nasal or sinus mucosa that fills with edematous stroma; others
believe polyps are a distinct entity arising from the mucosa. Based on
a review of the literature and several intricate studies of the
bioelectric properties of polyps, Bernstein derived a convincing
theory on the pathogenesis of nasal polyps, building on other theories
and information from Tos.
In Bernstein's theory, inflammatory changes first occur in the lateral
nasal wall or sinus mucosa as the result of viral-bacterial host
interactions or secondary to turbulent airflow. In most cases, polyps
originate from contact areas of the middle meatus, especially the
narrow clefts in the anterior ethmoid region that create turbulent
airflow, and particularly when narrowed by mucosal inflammation.
Ulceration or prolapse of the submucosa can occur, with
reepithelialization and new gland formation. During this process, a
polyp can form from the mucosa because the heightened inflammatory
process from epithelial cells, vascular endothelial cells, and
fibroblasts affects the bioelectric integrity of the sodium channels
at the luminal surface of the respiratory epithelial cell in that
section of the nasal mucosa. This response increases sodium
absorption, leading to water retention and polyp formation.?
Nasal Polyp illustration
?Your comment that the patient is being treated with Advair implies
that he has asthma. Prominent eosinophilia of this degree in an
asthmatic raises the possibility of:
a) aspirin-exacerbated respiratory disease with nasal polyposis and
perhaps associated sinusitis;
b) allergic bronchopulmonary mycosis (mainly aspergillosis). Check
serum IgE levels for marked elevation and obtain chest X-Ray when he
is acutely symptomatic looking for migratory infiltrates;
c) Churg-Strauss syndrome- look for chest X-Ray abnormalities,
granulomatous changes, positive serum ANCA (found in 60-79% of
?Allergic broncho-pulmonary aspergillosis (ABPA) cause prominent
pulmonary symptoms with migratory infiltrates and fever responsive to
steroid therapy. However, the skin manifestations described by you
would be very unusual in ABPA. A negative immediate skin test to
Aspergillus fumigatus would be strong evidence against this
?Churg-Strauss syndrome (CSS), or allergic granulomatous angiitis,
is a rare syndrome that affects small- to medium-sized arteries and
veins. Wegener granulomatosis (WG), Churg-Strauss syndrome, and the
microscopic form of periarteritis (ie, microscopic polyangiitis) are 3
closely related vasculitic syndromes that affect medium- and
small-sized vessels and are associated with antibodies to neutrophil
cytoplasmic antigens (ANCAs).
In 1951, Churg and Strauss first described the syndrome in 13 patients
who had asthma, eosinophilia, granulomatous inflammation, necrotizing
systemic vasculitis, and necrotizing glomerulonephritis.
The American College of Rheumatology (ACR) has proposed 6 criteria for
the diagnosis of Churg-Strauss syndrome. The presence of 4 or more
criteria yields a sensitivity of 85% and a specificity of 99.7%. These
criteria are (1) asthma (wheezing, expiratory rhonchi), (2)
eosinophilia of more than 10% in peripheral blood, (3) paranasal
sinusitis, (4) pulmonary infiltrates (may be transient), (5)
histological proof of vasculitis with extravascular eosinophils, and
(6) mononeuritis multiplex or polyneuropathy.?
?Churg-Strauss syndrome is a granulomatous small-vessel vasculitis.
The cause of this allergic angiitis and granulomatosis is not known.
No data have been reported regarding the role of immune complexes or
cell-mediated mechanisms in this disease, although autoimmunity is
evident with the presence of hypergammaglobulinemia, increased levels
of immunoglobulin E (IgE), rheumatoid factor, and ANCA.?
What is dysphagia?
Dysphagia is a term that means "difficulty swallowing." It is the
inability of food or liquids to pass easily from the mouth, into the
throat, and down into the esophagus to the stomach during the process
What causes dysphagia?
To understand dysphagia, we must first understand how we swallow.
Swallowing involves three stages. These three stages are controlled by
nerves that connect the digestive tract to the brain.
? A disease of the esophagus caused by the abnormal function of
nerves and muscles of the esophagus that makes swallowing difficult.
There may sometimes be chest pain. Regurgitation of undigested food
can occur, as can coughing or breathing problems due to entry of food
into the lungs. The underlying problems are weakness of the lower
portion of the esophagus and failure of the lower esophageal sphincter
to open and allow passage of food. Achalasia may occur at any age but
is predominantly a disease of young adults. Diagnosis is made by an
X-ray, endoscopy , or esophageal manometry (to measure the pressure in
the esophagus). Treatment includes medication, dilation (stretching)
to widen the lower part of the esophagus, and surgery to open the
lower esophagus. A fairly recent approach involves injecting medicines
into the lower esophagus to relax the sphincter.?
?A para-esophageal hiatal hernia that is large, particularly if it
compresses the adjacent esophagus, may impede the passage of food into
the stomach and cause food to stick in the esophagus after it is
swallowed. Ulcers also may form in the herniated stomach due to the
trauma caused by food that is stuck or acid from the stomach.
Fortunately, large para-esophageal hernias are uncommon.?
?Another mechanism that prevents reflux is the valve-like tissue at
the junction of the esophagus and stomach just below the sphincter.
The esophagus normally enters the stomach tangentially so that there
is a sharp angle between the esophagus and stomach. The thin piece of
tissue in this angle, composed of esophageal and stomach wall, forms a
valve that can close off the opening to the esophagus when pressure
increases in the stomach, for example, during a belch.
When a hiatal hernia is present, two changes occur. First, the
sphincter slides up into the chest while the diaphragm remains
stationery. As a result, the pressure normally generated by the
diaphragm overlying the sphincter and the pressure generated by the
sphincter no longer overlap, and as a result, the total pressure at
the gastro-esophageal junction decreases. Second, when the gastro-
esophageal junction and stomach are pulled up into the chest with each
swallow, the sharp angle where the esophagus joins the stomach becomes
less sharp and the valve-like effect is lost. Both changes promote
reflux of acid.?
? Severe chest pain
? Difficulty swallowing (dysphagia)
? Obstruction of your esophagus
?Regurgitation is the spitting up of food from the esophagus or
stomach without nausea or forceful contractions of abdominal muscles.
A ring-shaped muscle (sphincter) between the stomach and esophagus
normally helps prevent regurgitation. Regurgitation of sour or
bitter-tasting material can result from acid coming up from the
stomach. Regurgitation of tasteless fluid containing mucus or
undigested food can result from a narrowing (stricture) or a blockage
of the esophagus. The blockage may result from acid damage to the
esophagus, cancer of the esophagus, or abnormal nerve control that
interferes with coordination between the esophagus and its sphincter
at the opening to the stomach.
Regurgitation sometimes occurs with no apparent physical cause. Such
regurgitation is called rumination.
In rumination, small amounts of food are regurgitated from the
stomach, usually 15 to 30 minutes after eating. The material often
passes all the way to the mouth where a person may chew it again and
reswallow it. Rumination occurs without pain or difficulty in
swallowing. Rumination is common in infants. In adults, rumination
most often occurs among people who have emotional disorders,
especially during periods of stress.?
?Globus sensation is due to inflammation. Inflammation of many
different anatomic regions will produce a globus sensation: the
nasopharynx ("roof of the throat"), soft palate ("roof of the mouth,"
including the uvula, that little punching bag in the back of your
mouth), base of tongue, posterior pharyngeal wall ("back of the
throat"), larynx ("voice box"), hypopharynx ("lower throat") and
esophagus ("swallowing tube.")
Gastroesophageal reflux disease.
Chronic throat infection.
Other causes of globus:
?Cervical spondylitis (arthritis in the neck)
Cervical spondylitis is a very common condition and not all sufferers
get globus. However some probably suffer from increased muscle tension
in the neck and around the larynx causing globus.
Goitre (enlargement of the thyroid gland) General enlargement, nodules
and inflammation in the thyroid gland are quite common and can
occasionally cause a globus sensation. More often it can also be a
Patients taking diuretics ('water tablets' usually prescribed for high
blood pressure), ACE inhibitors (a specific type of drug taken for
high blood pressure and heart failure) and antimuscarinics (a group of
drugs used in a diverse of variety of conditions such as irritable
bowel, urinary problems and psychiatric conditions) can have
irritating or drying effects on the throat and occasionally cause a
Anxiety and depression
Patients are naturally worried that there is a serious cause for the
globus sensation frequently fearing they may have cancer. Fortunately
throat cancer is extremely uncommon particularly in people who do not
smoke or drink excessively and most cases are obvious from other
associated symptoms or on examination.
There is a higher incidence of anxiety disorders (including panic
attacks) and depression in patients with globus. Globus may be
experienced by individuals at times of emotional stress particularly
when they feel unable to express their feelings or when it would be
inappropriate to show their feelings.?
?Globus Sensation - Globus sensation (previously called globus
hystericus) is the sensation of having a lump in the throat when there
is no lump. Globus sensation may result from abnormal muscle activity
or sensitivity of the esophagus. It sometimes occurs when stomach acid
and enzymes flow backward from the stomach into the esophagus
(gastroesophageal reflux). Globus sensation also may occur with
frequent swallowing and drying of the throat brought on by anxiety or
another strong emotion or by rapid breathing.
The feeling produced by globus sensation is similar to that
experienced when feeling all choked up, such as during events that
trigger grief, anxiety, anger, pride, or happiness.?
?Recent studies suggest that gastroesophageal reflux disease (GERD)
may be a major cause of globus sensation. However, the incidence and
severity of GERD in patients with globus sensation without reflux
symptoms are unknown. In order to establish the relationship between
globus sensation in the jugular fossa and GERD, 20 patients attending
our ear, nose and throat (ENT) outpatient clinic with globus sensation
were investigated with 24-h pH monitoring.?
?This study suggests that globus may be associated with reflux, and
acidity does not have to reach the pharynx to produce globus
?Barrett's esophagus itself isn't associated with specific
symptoms. But, heartburn and acid reflux ? the sensation of
bad-tasting liquid that may enter your mouth from your throat ? are
common indicators of GERD. And having GERD can lead to Barrett's
A telltale sign of Barrett's esophagus ? which your doctor can notice
with a lighted instrument ? occurs when the color of the tissue lining
the lower esophagus changes from its normal pink to a salmon color.
This cellular process, called metaplasia, is caused by repeated and
long-term exposure to stomach acid.?
?Barrett's esophagus does not cause symptoms itself and is
important only because it seems to precede the development of a
particular kind of cancer?esophageal adenocarcinoma. The risk of
developing adenocarcinoma is 30 to 125 times higher in people who have
Barrett's esophagus than in people who do not. This type of cancer is
increasing rapidly in white men. This increase may be related to the
rise in obesity and GERD.
For people who have Barrett's esophagus, the risk of getting cancer of
the esophagus is small: less than 1 percent (0.4 percent to 0.5
percent) per year. Esophageal adenocarcinoma is often not curable,
partly because the disease is frequently discovered at a late stage
and because treatments are not effective.?
RAD (Reactive Airway Disease)/ RADS (Reactive Airway Dysfunction Syndrome)
?Ten individuals developed an asthma-like illness after a single
exposure to high levels of an irritating vapor, fume, or smoke. In
most instances, the high level exposure was the result of an accident
occurring in the workplace or a situation where there was poor
ventilation and limited air exchange in the area. In all cases,
symptoms developed within a few hours and often minutes after
exposure. We have designated the illness as reactive airway
dysfunction syndrome (RADS) because a consistent physiologic
accompaniment was airways hyperreactivity. When tested, all subjects
showed positive methacholine challenge tests. No documented
preexisting respiratory illness was identified nor did subjects relate
past respiratory complaints. In two subjects, atopy was documented,
but in all others, no evidence of allergy was identified. In the
majority of the cases, there was persistence of respiratory symptoms
and continuation of airways hyperreactivity for more than one year and
often several years after the incident. The incriminated etiologic
agent varied, but all shared a common characteristic of being irritant
in nature. In two cases, bronchial biopsy specimens were available,
and an airways inflammatory response was noted. This investigation
suggests acute high level, uncontrolled irritant exposures may cause
an asthma-like syndrome in some individuals which is different from
typical occupational asthma. It can lead to long-term sequelae and
chronic airways disease. Nonimmunologic mechanisms seem operative in
the pathogenesis of this syndrome.?
?Evidence has been accumulating that respiratory syncytial virus
(RSV) lower respiratory tract infection (LRTI) in infants may be
linked to subsequent development of reactive airway disease (RAD) in
childhood, and therefore research into the prevention of RSV LRTI may
have important implications for the prevention of RAD. This article
reviews the epidemiological evidence linking RSV and RAD and some of
the theories concerning cellular and molecular mechanisms of
post-viral airway inflammation in order to understand how RSV
prophylaxis may assist in reducing the occurrence of RSV LRTI and
?Why make the distinction? Why not just call it all asthma until
you're sure it's not?
There are three main reasons why doctors are hesitant to label a child
as having asthma when the diagnosis is unsure:
? Other illnesses such as bronchiolitis are not very responsive to
medications used for asthma. So, treating these children as asthmatics
only subjects them to medications they don't need.
? Other more serious illnesses may go undiagnosed if the reactive
airways are due to other factors but just labeled as asthma. By
diagnosing reactive airways disease, this leaves the door open to
entertain other ideas as to the cause of the wheezing.
? And finally, there are many insurance companies who make obtaining
health insurance difficult or very expensive if there is a child in
the house with a "pre-existing condition." It would be unfortunate to
label a child as asthmatic and cause insurance problems for the family
when over the course of time the cause of the reactive airways disease
turned out to not be asthma.?
?Heartburn (reflux esophagitis) also leads to asthma attacks. This
often occurs at night, when laying flat allows acid to seep back into
the swallowing tube and throat. If the acid leaks into your breathing
passages, choking and wheezing result. If your asthma attacks don?t
seem to be caused by colds, allergens, or other respiratory
irritation, consider reflux.?
?3. Reactive airway disease. This is actually not considered a form
of asthma, but it looks and acts similarly to asthma. In this type,
the child has asthma attacks only during colds. The lungs are
hypersensitive to cold viruses, causing the airways to constrict. The
child is generally well in between colds.?
? Zenker's diverticulum is a common, false, pharyngeal diverticulum
that arises above the cricopharyngeus muscle.
? Mid-esophageal diverticulum may be associated with diffuse
esophageal spasm or mediastinal fibrosis.
? Epiphrenic diverticula are often associated with achalasia.
? Diffuse intramural diverticulosis may occur owing to dilation of the
? Lower esophageal rings are of two types: (1) mucosal ring
(Schatzki's ring, also called B ring), which is located at the
squamocolumnar mucosal junction; it is common, and is associated with
characteristic history; and (2) muscular ring (A ring), which is
located proximal to the mucosal ring; it is uncommon, and is covered
by squamous epithelium.
? Esophageal webs are most frequent in the hypopharynx and cervical
esophagus and are distinguished by their location anteriorly. Webs may
also occur anywhere in the esophagus.
? Rings and webs can be treated by dilation.
Upper esophageal web due to a ring formed by a squamocolumnar junction
with ectopic gastric mucosa (another explanation of the
Paterson-Kelly, Plummer-Vinson syndrome)?
Plummer-Vinson Syndrome (also called Paterson-Kelly or sideropenic dysphagia.)
?Pathophysiology: The pathogenesis of PVS remains speculative.
Recently, even the existence of the syndrome has been challenged.
Postulated etiopathogenic mechanisms include iron and nutritional
deficiencies, genetic predisposition, and autoimmune factors, amongst
The prevalent iron deficiency theory remains controversial. Older
reports have implicated iron deficiency in the pathogenesis of
esophageal webs and dysphagia in predisposed individuals. The
depletion of iron-dependent oxidative enzymes may produce myasthenic
changes in muscles involved in the swallowing mechanism, atrophy of
the esophageal mucosa, and formation of webs as epithelial
The improvement in dysphagia after iron therapy provides evidence for
an association between iron deficiency and postcricoid dysphagia.
Anecdotal reports have also been made of patients with PVS exhibiting
impaired esophageal motility (with dysphagia) that recovers following
iron therapy. Moreover, the decline in PVS seems to parallel an
improvement in nutritional status, including iron supplementation.
However, population-based studies have shown no relationship between
postcricoid dysphagia and anemia or sideropenia. Other studies have
demonstrated that patients with webs are as likely to be iron
deficient as controls, and webs are often found in patients without
iron deficiency or dysphagia. Lastly, the iron deficiency theory does
not explain the predilection of webs for the upper esophagus and the
rarity of the syndrome in populations in which chronic iron deficiency
is endemic (eg, eastern and central Africa).
PVS has also been viewed as an autoimmune phenomenon. The syndrome has
been associated with autoimmune conditions such as rheumatoid
arthritis, pernicious anemia, celiac disease, and thyroiditis. In one
study, a significantly higher proportion of PVS patients had thyroid
cytoplasmic autoimmune antibodies compared to controls with iron
deficiency. The autoimmune theory, however, has gained little
acceptance to date.?
?Plummer-Vinson syndrome is a disorder linked to severe, long-term
iron deficiency anemia, which causes swallowing difficulty due to
web-like membranes of tissue growing in the throat.?
?When the lining of the esophagus is damaged, scarring develops.
When scarring occurs, the lining of the esophagus becomes stiff. In
time, as this scar tissue continues to build up, the esophagus begins
to narrow in that area. The result then is swallowing difficulties.
One of the conditions that can lead to esophageal strictures is
gastroesophageal reflux disease. Excessive acid is refluxed from the
stomach up into the esophagus. This causes an inflammation in the
lower part of the esophagus. Scarring will result after repeated
inflammatory injury and healing, re-injury and rehealing. This
scarring will produce damaged tissue in the form of a ring that
narrows the opening of the esophagus.?
?While the seasonal woes of spring and autumn translate into the
classic allergy annoyances of watery/itchy eyes and nose and profuse
sneezing, the allergens of summer generally manifest themselves in
nasal stuffiness and excess mucous in the nose and throat.
That's because the culprits vary from season to season. In early
spring, the pollens of budding trees (such as birch, poplar, walnut,
sycamore, oak and ash) produce the symptoms typically associated with
allergies and/or hay fever. Later springtime discomfort is usually
triggered by the pollens of such grasses as sweet vernal, bermuda,
timothy, red top, some bluegrasses and others.?
?? Frequent headaches, particularly those located over the nose and/or forehead.
? Breathing through an open mouth (rather than through the nose).
? Stuffed-up feeling in the nose - with or without discharge.
? Plugged-up feeling in the ears.
? Itchy, scratchy throat.
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Eosinophilic conditions throat or esophagus
Reactive airway disease
Adverse effects + Advair
Advair + Aspergillus
Advair + fungal infections
esophageal scar tissue