Yeah. All right, so thanks everyone for sticking around. And my memories are of malaria Ecologist E. N. T. Um specializing in voice and swallowing disorders. And with that I see a lot of patients who I believe you see as well with chronic cough glow biss throughout clearing. Um So let's go ahead and start. So, you know, we see a lot of these patients coming into our office is just a lot of throat irritation. Um Sometimes this is all encompassing both psychologically and physically they're unable to eat. Um They're losing weight and we can't quite figure out what's going on with these patients. So a lot of this this not quite effective throat clear and block. And obviously a lot of us are feeling this as well. So common symptoms associated with this condition include just a lump in the throat mucus, sensation, tightness. These are just a few of the symptoms that we're hearing. Um interestingly a lot of these patients say they can't swallow. Um although they're not drooling. Um they're not losing weight some of them and um they're able to eat and drink quite easily without signs of aspiration. But the common sensation is that they are unable to clear their mucus from their throat. Um You know, we create approximately 1 to 1.5 leaders of mucus a day. So patients always come to me and they sometimes show a picture of what they're clearing, which is either white mucus or clear mucus and they say, but there's mucus down here and I try to explain to them that that's normal Um in order to clear that mucus we are swallowing approximately 500-700 times daily. Um obviously much of this is automatic and autonomic and urologic and we're not quite appreciating that um, you know, Globe is I titled this hysterical different jesus. So first described by Hippocrates about 2500 years ago. So a lot of us have been closed throat clearing since then. Um, and then in the 17 hundreds were they actually did describe some researchers actually did describe in esophageal ideology to the globalists, but that was quickly dismissed and much of the 17 hundreds, 18 hundreds, as well as early 19 hundreds, the condition was attributed to psychosis, anxiety And hence they titled it global's hysterical. Um but in starting in the early 1900s until now we're learning more and more about how this is actually a physiologic process um and associated with actual organic underlying conditions. So, I know this is a busy uh, list here, but I just wanted to kind of bring up some of these. Uh so of course the causes are numerous and anything from psychogenic and anxiety to actual um esophagus or larynx ville or upper error. Any upper aero digestive tract cancer. Um and it's our job to try to figure out which one this is and of course it can be quite daunting sometimes, but fortunately there are some red flag symptoms that allow us to identify ideologies early on. Um interestingly one study about 15 to 20 years ago, 15 years ago showed that about 4% of global this is associated with an esophageal malignancy. Um now I think that's an overestimation. Um however, again it brings light to some interesting aspects that we should consider. Um going down the list of course allergic rhinitis associated with their common allergy symptoms. Even the tonsils stone can be associated with global sensation and I've seen many patients as soon as they express the stone, everything feels better. Life is better. Um esophagitis and gastroesophageal reflux has been um noted to be a proximate cause approximately 50% of global, so near substantial majority of these are sa fragile and ideology and sometimes the upper aero digestive tract and laryngoscope p and the upper airway is perfectly normal. They don't have allergy symptoms, They don't have turbulent hypertrophy. Um When we do a lot bronchoscopy, their larynx looks perfectly normal. So it's quite interesting that many of these sensations can be referred up to the throat. Um in fact, kind of going along with dysplasia. Many of our patients describe solid food dysplasia with food getting stuck inside the throat. In fact, half of those patients, the food is actually getting impacted in the distal esophagus. So we're not very good at describing where these sensations are coming from further kind of making this a little bit more of a difficult diagnosis. Um I think something that's interesting and something that's also over called is thyroid especially thyroid nodules. Unfortunately in my fellowship and in my practice I have seen patients undergo thyroidectomy is actually a good follow up on dr Aldama for benign nodules on the order of 1.5 centimeters. And practitioners believe that that was actually the cause of the of the global sensation. And I want to urge a lot of us to say that unless the thyroid disorder is actually causing compressive symptoms of difficulty breathing, difficulty swallowing um I would be very hesitant to remove a benign knowledgeable just for the sensation of globus. Um of course adenoid hypertrophy sinusitis. Um There are some medications that can cause a sensation of globalists or specifically um increased konyukhov as well, such as ace inhibitors were all very familiar with those um other medications or anti colon urgency as well. Those are notorious for causing these sensations. Some medications can cause um uh esophageal inflammation like Tetris cycling, clindamycin, doxycycline and that could cause a severe global sensation as well as throat clearing. Um Other medications like Januvia can cause significant gastric stasis or decreased gastrointestinal motility, increasing gastroesophageal reflux as well. Um Of course we're all familiar with bisphosphonates causing severe acid reflux. Um tricyclic antidepressants can cause um delayed gastric emptying as well. Um Other causes of esophagitis would include C. M. V. H. S. V. Fungal esophagitis that we see commonly in our immuno compromised patients and many of these patients do describe a global sensation as well. Um I put up here a picture of the quick reference this muscle. So what you can see here is the cervical spine, the clavicles. This is barium contrast material sitting within the bearings, the patient's pointing there to the left, the back of the head is up here and here's the chest. Here's normal bearing contrast in the throat and here is the quick offering jesus muscle which is essentially part of our upper esophageal sphincter um limits. Um What we think it's due to what we think it's it's there for is to actually naturally prevent gastritis. Gastroesophageal reflux contents into the throat. Um So when we swallow that muscle is supposed to relax and food is supposed to go down easily. But here is an image of the muscle not relaxing but actually a pretty severe obstruction. This has been associated with just global sensation. Of course with dysplasia. However a study out of china showed that um there was a statistically significant association between people who had anxiety and increased upper esophageal sphincter pressures. So we don't know which is which is that the actual something neurologically is going on with that muscle and they have this chronic sensation of globus or is it the I have a lump in my throat because I'm nervous and that's what's causing that sensation. So interestingly there is a physiological explanation to the um symptom moving on. So I put a bunch of other things here as well. So you know if you have a very if you have very large um cervical hardware sitting right behind the bearings that can give you global sensation as well. Um Anything going on within the throat like a ferengi seal, a ferengi assist, Lorenzo closest. Um I think muscle tension dysphonia is a big one that's under recognized, so tension in the throat and then in the, especially in the larynx associated with hoarseness, people get a lot of muscular tension, a lot of tightness and that could be quite debilitating to them as well. One thing that I'm going to focus on here is going to be superior angel nerve neuropathy which is what we suspect is a traumatic or post viral cause of inflammation to the main sensory nerve that goes to the larynx causing chronic chronic throat clearing glow base as well as chronic cough. So kind of pointed out some things with regards to globus and essentially with chronic cough, very similar picture here. So the two really do overlap in terms of symptoms and um patient complaints. So approximately 20 years ago in the larynx biology literature, this concept of the irritable larynx came up um which is similar sensations against road clearing cough, difficulty swallowing mucus. And I like to think of this as a spectrum anywhere from I have a lump in my throat sensation to I just can't stop coughing most of the time or actually predominantly if this is a neuro genetic type cough um E like a vocal cord spasm it should be a dry hacking cough, any cough that is wet. Should should raise other types of suspicions. So other words that other terms that we use to describe this type of throat irritability is a neuro genic cough Vegas neuropathy. As the superior. The original nerve is a branch of the vagus nerve um Irritable larynx syndrome interestingly probably took that from our G. I. Colleagues um as well as vocal cord dysfunction. So some of these patients may describe the inability to breathe. I'm sure some of you have seen patients that have developed um severe strider and a choking sensation, some have actually gone to cinco pies and that can many times be from an actual paradoxical motion or vocal cord spasm mechanisms quite unclear at this point. But from a neurogenesis neurogenesis perspective we think it's the hyperactivity of the sensory fibers in the upper airway uh specifically the alpha and C fibers. Um And I'm going to actually talk about some medication or a medication that's actually being studied currently to try to suppress that um many different types of evaluations. So questionnaires. So if we're trying to understand what's causing this a reflux severity index. To understand whether this is associated with LPR um cough severity index. How severe is this reflux findings within the larynx as well as whether the patient is actually also developing voice issues. And that could suggest a vocal ideology as well. Um I'll show some videos of this in my next talk but video stream colonoscopy specifically video store pOSCA p compared to large endoscopy I think is actually crucial in diagnosing and excluding other causes of global this um esophagus copy um to be to piggyback on dr Butler were actually um you can actually perform an esophagus copy in the office um at the very least an awake patient under local anesthesia. And this is with the advent of a trans nasal esophagus scope under just applying a little bit of lidocaine spray to the nose and going all the way down into the stomach. Um We can't evaluate the small intestine as these are shorter scopes but they are much narrower and they are channel scope. So we could do interventions, Botox injections biopsies as well as steroid injections right in the office. And it's quite remarkable that patients get a complete upper aero digestive tract evaluation in 15 minutes um imaging of course, chest x rays, neck imaging um in specific cases chest cts of chest cts as well. Um I work closely with our pollen ology colleagues in order to rule out asthmatic cough, eosinophilic cough, pulmonary function tests of course to rule that aspect out. And I think pH studies are crucial as most of these patients are, most of these patients symptoms are due to either LPR Lauren go pharyngeal reflux or GERD um treatment is um we typically start with treating that, but ultimately, if we can't find the cause we do move move onto ph studies. Um Common ph studies would include like a 24 hour impedance study, uh just a small catheter that goes through the nose and sits in the stomach, um a little bit uncomfortable for patients because it is a 24 hour study. They do go home and they have a small wire sticking out of their nose for that period of time. Um Yeah, it's but I think it's very helpful. Um The benefit of that is uh well, I'll explain the benefit in just a second. There is another type of ph study that's called bravo. Um and this there is no external wire. This is a small ph monitor that's placed into the distal esophagus, endoscopic lee. Um So, benefit of that is that the patient has no idea that that there's something there. The disadvantage is that they do have to undergo a moderate sedation and endoscopy to place that probe. Um The benefit of again, ambulatory ph is that they don't have to do that. Another benefit of it is that dr griffiths earlier alluded to non acid reflux. So we have a lot of these patients who don't respond to PP. I therapy. Um Yet they're still having these symptoms. So ambulatory ph actually has a special type of catheter that can measure just the volume reflux. Not specifically, acid reflux and that gives rise to this whole idea of peps in and pepsi in again in the upper airway causing symptoms. Ultimately it is a digestive enzyme. So what is it doing up in this area? There are some I have seen some people use like cheap swabs for peps in I think the research is um not quite um convincing of whether that's quite specific or sensitive in diagnosing these types of conditions um and ultimately high resolution manama tree. So if we're trying to evaluate, evaluate for pressure issues, motility issues like I showed earlier that um quite different genus muscle, the hyper tone, the hypertension city of that muscle or whether this is some type of ineffective esophageal motility like nutcracker, esophagus, esophageal spasm, hypertensive esophagus, that would be the study of choice. So, in terms of treatment, let's say, we've ruled everything out and now we're left with the point of um what we would call idiopathic. Um I start moving my patients towards this idea or notion of the superior angel uh neuropathy or chronic hypersensitivity, hypersensitivity or excuse me, neuropathic cough. So tricyclic antidepressants namely a level have been helpful, especially with nighttime symptoms. These patients are waking up with a cough. Um gabapentin tin can also be also be quite effective. I tend to shy away from opiates just because of the risks associated with them the over the counter medications. It's a multibillion dollar industry, you know, again, we walked to the pharmacy just a huge area on allergies, Reflux, cough. So that's a huge industry as well. How effective? Not quite sure. I don't think it's that effective ultimately for chronic cough. Um And then we are with our speech language pathologists. We move towards actual therapy for retraining this hypersensitive larynx. So there's respiratory retraining therapy, cough suppression therapy that has a lot to do with avoiding triggers as well as specific breathing techniques. I also utilized botulinum toxin to reduce the spasticity of the vocal cords as well as superior and Jill nor cough. I'll move through this quickly. But essentially these are some studies that have shown the procedure called Super 11 junior Block for treating the uh I'm sorry for treating treating the uh neurologic hypersensitivity in the throat. So this was initially um used by our anesthesia colleagues for um awake intubation in patients that couldn't undergo actual general anesthesia. They would block the superior leering joe nerves within the neck and that would cause complete Lorenzo um uh numbing. So we've actually found that blocking this nerve in the office has reduced chronic cough, glow biss, um throat clearing uh in settings of superior laryngeal nerve neuropathy. Um Quite easy to do. Just identifying loren gill net landmarks. Um injecting right into the membrane between the between the adam's apple or the thyroid notch and the hyoid bone and I like to inject triumphs in alone or catalog as well as Mark Twain For some patients that we're not quite sure whether it's going to be helpful. Um I just go ahead and inject 2% of like lidocaine um risks that three out of 60,000 patients have shown to develop blindness associated with any type of catalog injection uh, in the head and neck, specifically for the turbine. It's um, and that's specifically due to the particulate of the steroid going and intra arterial and eventually traveling to the brain. So we could do things technique wise to avoid that. Um, some centers inject up to six times. I personally inject three times max on both sides um since we don't know much about it, but I have seen patients come into the office miserable. They can't talk, they can't swallow their constantly clearing their throat. They feel like there's something there. You do one block and they're happy within a few weeks. So it's quite a remarkable thing that we've started to do recently. I just want to open up for questions, otherwise I'm happy to move on to the next. I'm not sure. Right? So this one's gonna include a lot of videos. I think just um, you know, they say a picture's worth 1000 words, so we'll move quickly through that as well. Um so hoarseness, any condition that could, that alters normal vocal cord physiology. Um You know, I think this is an area of our anatomy that not many of us see. Um we don't really know what's going on down there. So I kind of wanted to open this up to just show you guys what I see on a regular basis and how you can apply this to your practice. So when I show my pictures there, laryngoscope e in the office I get responses from gross to wow as well as G rated two X rated comments and what this could potentially be. Um But just to orient you, the top of the screen is the poster of torrential wall uh left is right and right is left. So we're looking straight down the larynx here. Um The regenerate cartilage is are essentially the joints that control the motion of the larynx. Um They can move along the X. Axis up and down y. Axis. And they could also actually rotate as well. So there's over six paired muscles controlling each vocal cords. So you can imagine that's what's responsible for such profound are profound ability to produce voice. Uh The vocal cord is made up um generally into three layers. What we call the body cover theory. Uh So the deepest layer which is most of the slide here. The histology here is the vocalist muscle which is what's responsible for shortening and elongating the vocal cord. Uh There is a layer called the lamb inappropriate between the blue epithelium and the muscle. Um And that is made mostly of gelatinous of a gelatinous matrix as well and that's what allows the vocal cord epithelium to essentially vibrate and create the frequency or the fundamental frequency of our voice. Um I just want to differentiate voice from speech of course. You know we have a lot of therapists who performed speech therapy and Children um And that is due to our throat or tongue are soft palate especially our lips and our mouth. But specifically voice production has to do with the larynx. So here's a normal air endoscopy patient's breathing and saying E. So that's an E. Sniff with the vocal cords closing in the vocal chords opening. Um And then I want to show you what vocal cord function is without strong bosc api. So there you could just see the patient saying, I'm just going to show you that again. So you can see that they're coming together, they're closing and they're opening normally. But as soon as we introduce this special camera and light source, not like, excuse me not camera but light source called Strabo sebas copy. You can actually I think it's coming up pretty dark. Right? Okay. Um Can you guys see that? I can't tell. No. Okay. Well anyway what what sebas copy does is stops um the image of the vocal cord vibration at each stage of its vibration. And men the the epithelium glides back and forth, approximately 100 and 2200 and 40 times per second. And women it's a little bit higher 180-200 times per second and strobe Oscar p imagine it like this high speed camera, it freezes the frame at every part of that cycle. And via just some algorithm show shows us that glide of the vocal cord. Um and it's quite remarkable because it could show things that we wouldn't see otherwise. So, just some common symptoms of hoarseness or common complaints, hoarseness, rough week, strained muscle tension, And just some common acute causes. Of course, we all see viral laryngitis self resolving within 3-5 days every once in a while, we can see a superimposed bacterial laryngitis typically from either like severe tonsillitis or severe sinusitis with the bacterial stuff draining down into the throat. This is an example of a vocal cord hemorrhage. So a ruptured blood vessel underlying this epithelium here. You can see the famous italian or the blood deposits there as well. And of course, voice misuse overuse. Going out to the clubs to the bar, shouting, talking a lot. We all have gone home the next day have had a lot of hoarseness. Not all of us maybe, but tends to happen. Um Of course, with any hoarseness. Red flag symptoms, difficulty swallowing, difficulty breathing, strider, of course. Um blood in the saliva and usually any systemic findings that aren't usually analogous analogous with an upper respiratory tract infection, chronic hoarseness, any horses lasting greater than three weeks. Um So if you find it's associated again with any of these symptoms, I would recommend more urgent referral or at least evaluation rather than just sitting on it. So, in terms of the Lorenzo aspects here, so things that I see quite commonly again, Lorenzo pharyngeal reflux, nodules, polyps insists, um vocal chord paralysis, which is similar to vocal cord paralysis but much more subtle at times um infectious uh something that I think is quite under recognized the aging voice, Especially in our population, greater than 65 neurologic conditions, uh, systemic, such as TB sarcoidosis, rheumatoid arthritis. Um, these can all present in the larynx as well, as well as cancer. So, just because we've talked about this a little bit, I'm gonna move on from here. Uh so just kind of wanted to show you what an inflamed larynx can look like here. If you can remember kind of what the last one looked like here, You can see how things are generally so much more swollen. The back of the vocal cords is the dentist. The vocal chords themselves are swollen. Um The actual esophagus is that here, so you stomach, yeah, smoking toys. And it's a really swollen voice box and you can imagine how people can come in and say this, I feel like there's a ton of mucus sitting in my throat and you will look when you look down there, there's no mucus or abnormal mucus, but it's actually quite swelling and unfortunately it's difficult to um educate patients on this aspect because they'll still continue to clear their throat, clear their throat and you can imagine the more throat clearing they do, the more inflammatory that will be. And it's just this chronic snowball of effects. So we really try to break the cycle in a lot of these patients to get them to feel better. Same thing with chronic cough. We tend to quote unquote, give in to the cough when we get these neurogenesis coughs. So if we can at least try to break that cycle a lot of times it could go away on its own. Um Here's an example of a traumatic or hemorrhagic polyp and a patient. So this is actually quite a large polyp on the left vocal cord. Um treatment for these is surgical. Unfortunately when they get this big they don't tend to go away with voice therapy. Um So we take these patients to the O. R. Through the mouth. Nothing is done externally and do a micro flap or a very meticulous dissection between healthy and abnormal vocal cord and remove that under the microscope, smaller polyps can be treated with voice therapy. Um However this size I definitely would not recommended um vocal chord nodules. See them all the time typically and people who need to talk a lot lawyers, teachers of course singers. Um younger patients who are going to school and are generally social people by definition nodules are always bilateral. Um Think of these as a callous, you know you were about shoe, you walk all day, you get a callus on your foot. Well if someone's talking all day or misusing their vocal cords, creating a lot of attention, they get these bilateral thickening of the actual epithelium of the vocal cord. These are very dynamic in that if you stop talking for 1-2 weeks they tend to go away. Um psychologically we can't ask our patients to stop talking for 1-2 weeks um especially if that's the reason they're occurring in the first place. So um that's why the help of our speech language pathology, our voice therapists are quite crucial in the treatment of these pathologies. This is an this is an image of an aging of a patient with aging voice. So here you can see that the vocal cords are no longer straight and linear and when they come together here in the posterior aspect there's still a large gap along the anterior aspect of the vocal cord. Um so we see these in about a quarter of patients over the age of 65, very common. And a lot of my patients at this age are actually quite active, described kind of lack of confidence, emphasis on authority in their voice. Um and these are relatively easy to treat. So we can treat these with voice therapy basically teaching patients how to emphasize their voice from a diaphragmatic and a pulmonary aspect, reducing the tension in the neck and the throat um to in office injections as dave had as they've had alluded to. So most of these procedures are again done in the office under local anesthesia. We put a scope down the nose, visualize the larynx. Um Get a filler material um either materials that last anywhere from two months to a year and a half um going through the skin of the neck. Put the needle here directly into the vocal cord and inject the solar. And that means realizes the courts and allows them to come together. So vocal cord paralysis. Very common voice in these types of patients. Very breathy, very weak. Some may actually present with um liquid aspiration of liquids because the vocal cords are unable to come together completely. Um Most common cause is i a transgenic or surgical. Other common causes would be idiopathic. We think it's post viral but not quite sure. Most of those do recover within um six months, 90% of those do recover within six months. And um other causes like a stroke um trauma. Um As well as of course the most important thing to rule out here would be some type of neo plasm. Uh So any type of mass that's um encroaching or putting pressure on the recurrent laryngeal nerve can cause this type of issue. Um And that recurrent Lorenzo nerve runs anywhere from the skull base down into the chest. Um So we typically do engage in imaging to to rule that those aspects out and again, these patients don't need to walk around with a very breathy voice, they do benefit highly from an in office augmentation to treat their condition. I'll skip this one for now, since I don't think you guys can see it. Anyway, vocal tremor, this is really interesting. So um essentially we can we can develop an essential tremor of our voice box as well, similar to an essential tremor of our extremities. Unfortunately, medications used to treat um extremity, local essential tremor are not that effective for the throat. Um so we tend to send these patients for voice therapy because that can be effective. Um but a wonderful treatment for these patients is botulinum toxin or Botox, into the Larynx. Um it's quite remarkable the doses that we start with our fractions of normal doses doses. So typically in my elderly patients I'm using .0625 units um to begin and I incrementally increase by .25 units. So average dose about 2.5 units into each vocal cord and it does substantially improve their tremor. So I want you to kind of see it here. So you could see this kind of fluctuating muscle spasm show you that again, so you can see how dramatic it can be and the more anxious the patient gets about this voice, the worse it gets. So unfortunately again it's one of those things that just compounds on itself. So many of these patients describe having the Xanax or having a glass of alcohol and it tends to go away. But again we tend to inject the Botox directly into the vocal chords again in the office and it significantly reduces the tremor. Yeah, adductor, spasmodic dysphonia is also something, I'm sorry, spasmodic dysphonia is also something that I think is under recognized and we can treat quite easily. Um These are patients with a very spastic voice. Um I have a video but we won't go ahead and look at it right now. But essentially these patients um have breaks in their speech so they like the and that's a pretty dramatic example. So you could have think of this as a vocal dystonia. Again, an inappropriate spasm of the vocal cord. Um you could have this affecting the vocal cord muscles that are meant to close the vocal cords and that's when they have a very spastic uh tight speech. Um Sometimes it actually can cause um affect the muscles that open the vocal cords. In that case these patients can have a very breathy breathy voice. Um and these can be identified on specific vowels and syllables in the office. Um Some cases it's mixed and these trees these pathologies are primarily treated with a with Botox. I just want to bring your light to this. This is a patient that came to me, her chief complaint. She was referred to me with hoarseness. Um just wanted to see that not all hoarseness is vocal cord but this is subplot stenosis here. So if you watch her saying E and then open you can see that significant and large scar band right in her vocal cords. So right there. So here the courts. That's the start there and that's yeah. So again the referral for this patient was hoarseness not strider, not difficulty breathing. So um these tend to occur either via intubation, traumatic. Um There is a large cohort of women typically caucasian starting in their forties to fifties developing idiopathic subplot X. Stenosis. We typically treat these in the operating room with dill ations, lasers as well as steroid injections. And lastly um squamous cell carcinoma of course. So um most of these patients are nearly asymptomatic especially if it's early stage bladder cancer. Um except for hoarseness, they don't have any difficulty swallowing. They don't have pain. Um They may have a little bit of a cough but again they come in with hoarseness and we have very special types of light that could actually pick up on irregular lesions. So the green here you see is a special type of light called um narrow band imaging which allows and I think the gastroenterologists use it as well as well and allows us to evaluate the vascular charity of the mass differentiating between benign or at least suggesting whether this is a benign or malignant process. So that's all I have for you guys today and if I could invite any questions, I'd be more than happy to.