Patient: Swallowing disorder for 8 years, aggravated for more than a year, many seek medical help to no avail, online read a lot of your medical literature, know you are an authority on swallowing disorder, so I came here to seek help. Basic situation: 1, 24 years old, male, do not smoke, rarely drink, college students, because of poor swallowing, afraid to eat large and difficult to chew food, such as vegetables, fruits, severe malnutrition, a variety of vitamin deficiency, eating less, the body is very thin. 2. The tongue is light white, the stool is basically normal, there is bad breath and bitterness, especially in the morning when you first wake up, no food injuries, phlegm is basically white sticky phlegm that cannot be coughed up, sometimes with food residues, and in winter it may be bloody. In the past, before swallowing was not very difficult, I could cough up thick sputum smoothly after three meals, but now I basically can’t cough up, and it is very uncomfortable, and the problem of swallowing difficulty has become more serious. 3. The cause of this disease is that I felt stuck when I swallowed a mouthful of vegetables in 2001, and I was very scared at that time. Recent illness: 1. During the process of eating, as more and more food residues or phlegm remain in the throat, foreign body sensation becomes stronger, the more difficult it is to swallow, and then some residues run to the nasopharynx, resulting in poor breathing. 2, after eating always want to drink hot water to clear the residue, sometimes can feel a large mouthful of phlegm, with the taste of food, feel not washed down by the water, can not cough, seems to hinder breathing, very uncomfortable. 3.After eating for a long time, sometimes food residue can be found in the sputum coughed up, and it feels that the nasopharynx is very uncomfortable because of these food residues. 4, because of normal swallowing always feel food stuck, even breathing is difficult, all eating is always subconsciously swallowed to the side of the throat, food down slowly, sometimes even feel not down, it is difficult to swallow the next bite, to slow down and so on food down before you can continue to barely eat. And it seems that eating from that side of the throat when eating will produce a foreign body feeling over there, the corresponding side of the nose will be nasal congestion. 5.Nasal congestion is often on the left side of the nose, and there is a strip of phlegm at the root of the nasal cavity that cannot be sucked out. 6.After meals or drinking water, there has been a rush of gas to the throat, I do not know whether it is belching? Or pharyngeal muscle spasm? I don’t know if it’s belching or pharyngeal muscle spasm, but there is a foreign body in the throat that keeps burping. Is this belching or pharyngeal spasm? I heard that pharyngeal spasm can lead to swallowing disorder, is this my case? I have been examined: 1. October 2009 barium meal imaging of the upper gastrointestinal tract did not show any abnormalities (my doctor told me to rule out esophageal achalasia) 2. July 2009 CT scan of the paranasal sinuses did not show any significant abnormalities (but I often feel serious nasal congestion on one side after eating, so I don’t know why) 3. October 2008 electronic gastroscopy report form endoscopic observations: esophagus: no abnormalities. cardia: no abnormalities gastric fundus: mucus paste clear, small amount. Gastric body: reddish-white, mainly red, florid-like changes. Gastric horn: no abnormality seen. Gastric sinus: It was red-white, predominantly red, with florid-like changes. Pylorus: subround, well opened and closed, no bile reflux. Bulbous part: no abnormality was seen. Descending part: no abnormality was seen. Endoscopic diagnosis: chronic superficial gastritis HP (+ -) 4. November 2008 electronic laryngoscopy report form endoscopic findings: tongue root, posterior pharyngeal wall with massive lymphoid follicular hyperplasia. The surface of the epiglottis is light red, and a few blood vessels are visible on it. The mucous membrane of the laryngeal cavity was mildly congested, the vocal cords were lightly congested with blunted edges, and the vocal cords were inwardly retracted bilaterally when pronouncing the “clothes” sound, and the vocal folds were still closed. The mucosa of bilateral arytenoids and bilateral arytenoid folds was smooth, and when the “clothes” sound was produced, the bilateral arytenoids and bilateral arytenoid folds were invaginated, the bilateral arytenoids gap was closed, the pear-shaped fossa was clearly exposed, and the mucosa of the bilateral pear-shaped fossa was light red and the surface was still smooth. No obvious neoplasia was seen in the bilateral vocal cords, laryngeal chambers, and pyriform fossa. Diagnosis: Chronic pharyngitis {Note: In 2006, the above two tests were also done, and the results of the tests were Gastroscopy: Bile reflux gastritis Duodenal bullae HP (-) Laryngoscopy: Chronic pharyngitis} Describe the eating situation: 1) When eating dry food such as bread and cookies, you need water to swallow smoothly, without water, you feel that the downward movement is very slow, and you feel stuck. The more you eat, the more you can’t eat feeling. (2) When eating, there is a feeling of food residue stagnation in the throat, and produce a lot of phlegm, more and more, and finally feel completely blocked, afraid to eat, so the amount of food is less. (3) eat or drink water do not dare to finish eating or drinking in one breath, the mouth has to be stuffed in the swallowing point down, because always worried about being gambled, leaving some good to swallow the blocked, drink water always habitually drink a large mouthful of some down, spit out some, eating is also continuous to the mouth stuffed food, the last bite to stay spit out, because if all swallowed is always feel blocked, and there is nothing else to put it down, very uncomfortable. (4) Every time I swallow a bite of food, I feel that it is slow to swallow, especially in this part of the throat, and at the same time, the nasal airway is blocked and I feel that I can’t breathe well, and when the food goes down, I feel that my nose is ventilated all of a sudden, and I can continue to swallow food after taking a few breaths to relieve myself. Therefore, every time I eat, it is a headache, very painful, others enjoy eating, but I feel like suffering, but want to eat, must eat, very painful. (5) Because I am afraid that my throat will be completely blocked, I always subconsciously swallow from one side when I swallow something. The foreign body feeling is obvious on one side of the throat, usually the left side, and often the foreign body feeling appears on whichever side I eat on, and nasal congestion appears on whichever side. Hiccups in the throat, belching, belching always feel that only one side of the throat is open, the other side is not open, and sometimes feel that both sides are not open, how to belch can not belch up, it is very stuffy, breathless, very uncomfortable. (6) Because of the fear of choking on a large food block, so whatever I eat is chewed very finely (I do not know if there is any harm to the stomach), and I swallow carefully in small bites, but there is also the above feeling, and I feel that the more I chew, the easier it is to get stuck, the more nervous I feel stuck, and the more I eat water, the more I get stuck. Overall feeling: feeling of foreign body blockage in the throat, difficulty in swallowing, coughing and sucking sputum, basic painlessness, sometimes burning sensation when food reflux, nasal airway is gambling sensation, poor breathing sensation, feeling of slow downward movement of eating food, feeling of food residue retention, frequent and poor belching sensation, feeling of mental tension when eating. Detailed symptoms: I. Nasopharyngeal symptoms (mainly nasal) 1) There is a more obvious feeling of food stagnation in the throat during eating (as if on one side), and it is felt that food residues easily enter the nasal cavity, and there is a strong feeling of phlegm or food residue adhesion at the root of the nasal cavity, so there is often an obvious feeling of dyspnea after eating. 2) The above sensation is even stronger after eating. If a large food lump passes through the stagnation during the eating process, one feels that the food is stuck, belches frequently and feels that the belching is not smooth, or wants to burp. 3) Belching also occurs on an empty stomach, and I wake up several times at night to belch (once every two or three hours, poor sleep). Two reasons are analyzed to aggravate belching: a foreign body sensation in the pharynx, which can lead to dry heaving, and excessive straining during eating, which results in swallowing a large amount of air, plus the presence of chronic superficial gastritis itself, so belching with reflux is more severe. 4) Sometimes I belch but cannot belch up, and I always feel that I am being held up by a film made of phlegm at the root of the nasal cavity in my throat, and when I do not belch up, I find it difficult to breathe. 5）I can’t sleep flat on my back because I snore and can’t breathe well (I didn’t before). According to my classmates, recently, sometimes the snoring becomes a strange sound and shows a painful appearance, and the frequency is high, more than once every ten minutes. 6) In winter, in the morning, there is often blood in the nasal discharge or a small amount of blood clots, and there is also blood in the sputum coughed up. If you feel that eating is more uncomfortable, i.e., you often have the feeling of poor swallowing during eating, or even the feeling of serious retention of food residues, blood may also appear in the nasal discharge or sputum after eating. 7) Due to weaker body, every year in autumn and winter, the nasopharynx produces a large amount of thick green sputum or nasal mucus, but since July 2008 when swallowing has been poor, these symptoms disappeared and there is only little nasal mucus or sputum, and it is mostly white, even if there is thick sputum or thick mucus in small amount and in small pieces. 8) Suspected lesions in the nasopharynx, but repeated examinations were not supported and felt that there was something wrong with the examination. Both e-nasopharyngoscopies were performed from the left side of the nasal cavity and the second one did not examine the nasal cavity in detail, and the doctor said that the right side was not easy to examine. The nasal cavity was basically free of nasal mucus and no pain. (9) I feel that there is no foreign body in the nasal cavity, but there is a feeling of phlegm sticking to the root of the nasal cavity, that is, where the airway meets the throat. (10) When bending over or leaning forward, the airway feels completely blocked when the face is facing down, and the whole face has the feeling of being pressed, so that it is impossible to breathe through the nose and must open the mouth to breathe, which was not the case before or is not as serious as now. Second, pharyngeal symptoms chronic pharyngitis has been diagnosed, there are extremely typical symptoms of chronic pharyngitis, but I do not know whether it is due to neurological reasons or other aspects, but also accompanied by dysphagia, dysphagia caused by pharyngitis is due to pain, but I generally do not feel pain, at most, reflux with burning sensation, had self-suspected hysterical ball syndrome dysphagia. The general situation of the throat: rarely painful dry throat feeling, burning sensation when food reflux, foreign body feeling on one side, no pain in swallowing, self-conscious throat is very blocked, there are a lot of phlegm, often clear the throat, but can not clear, more spit out white phlegm. I feel that my throat and airway have become smaller or swollen, or are blocked by phlegm, or are compressed by a foreign body, making it impossible to swallow large volumes of food, and I cannot breathe well. Especially afraid of choking, so when eating is very nervous, food is always chewed very small, slightly larger food through the throat can be felt, this time the mental tension, often then feel that food stuck. Because of previous cases of choking on larger pieces of food, it is difficult to breathe afterwards, and belching is frequent and uncomfortable. Since the nerves in the throat are very sensitive, I suspect that there is something wrong with the nerves in the throat. I used to have thick snot every winter and spring when the weather was colder (I used to have pharyngitis), but I could spit out or jerk out a lot of thick phlegm every time I got out of class, so I didn’t have these problems. It seems that the symptoms described before, such as difficulty in swallowing, breathlessness, and strange noises in sleep, have worsened because of this change. What do you think I should do to solve this problem and what could be the cause? Patient: Thank you for taking the time out of your busy schedule to answer my questions. I will analyze the items in the article and mark the ones that match mine in yellow, please help me diagnose and give me some suggestions if you can, and I will go to you for diagnosis when I have more time. The attachment has been sent to your email, sorry again! Patient: By the way, I did this Japanese Kubota’s 30mL drinking test Grade 1 (excellent): can finish 30mL of room temperature water in one sitting without choking or pausing. grade 2 (good): finished in two sittings without choking or pausing. grade 3 (moderate): can finish in one sitting but choking. grade 4 (OK): choking even if finished in two or more sittings. grade 5 (poor): repeatedly choking and coughing, difficult to finish all the water. Since I subconsciously leave some in my mouth every time, I chose 40ML for the test, basically I can drink it all at once and leave very little in my mouth, from this point of view, it can be considered a level 1 situation, I don’t know why food is afraid to swallow, especially the larger size, it is more afraid, often to be stuck. Patient: Hello Professor Cheng, I read your article: “Patients with undetected underlying neurological disease presenting with swallowing disorder as the primary symptom. It can be mistaken by clinicians for esophageal disease or structural disease without thinking of neurological disease. Dynamic imaging can make the difference. Occasionally, a patient presents with what appears to be a neurological swallowing disorder. However, a closer look reveals that the patient has a psychiatric disorder. Patients with this type of psychiatric disorder are younger and stronger, and their oropharyngeal swallowing disorder symptoms can be mild or severe, often fluctuating widely. Swallowing disorders due to psychiatric disorders often have no dysphagia and negative neurological examinations; video imaging examinations are often normal at the beginning, but later there is often a delay in the onset of swallowing and complaints of inability to swallow, while the range of motion and coordination of the structures of the parts revealed by the imaging are not abnormal.” I think this is pretty much the case, so what should I do?