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Wednesday, April 23, 2014
Ear, Nose, and Throat Disorders
Pain in area of hyoid bone left side
I have had continuing (not sharp or lancinating) pain, soreness and aching that varies in intensity in my neck - left side of hyoid bone for the last few years. I feel pain in a spot near where my tonsil was removed (many years ago) when I swallow. I also have a low grade earache most of the time and also tinnitus. The pain often radiates up the back of my neck on the left side up my scalp behind my ear. I am often hoarse and have to clear thick phlegm from the left side of my throat. I have had CT scan, MRI, MRA and nothing shows up. I have been tested for reflux. An ENT removed my submandibular gland, but the pathology report showed that the gland was normal. I have had two complete neurological workups and neuralgia has been ruled out and no neurological cause for the pain was found. I have been tested for allergy and have none. My nasal passages are clear and there is no sinusitis. Today at a physical therapy visit, the PT told me that my hyoid bone is rotated to the left and clicks when he glides it. He believes that the hyoid bone is scraping against the trachea and throat structures when I swallow or move and this is causing my pain. My question is where do I find a otolaryngologist who can correctly diagnose and treat this problem? I have seen numerous otolaryngologists over the past seven years. They have been puzzled by my symptoms, but not willing to investigate enough to come up with a diagnosis. I realize that my condition is probably rare, but what would I look for in the credentials of a specialist to help me? The PT thinks I will probably need surgery to correct the problem.
The neck is a very complex area of anatomy with many structures that can cause pain. To make the matter even more confusing, pain in one area of the neck can be referred to or from another area. For instance, throat pain often manifests with contiguous ear pain. The first task of the physician would be to rule out something dangerous, such as a pharyngeal carcinoma causing throat and ear pain or a carotid artery dissection that can lead to a stroke. The comprehensive work-up has ruled these things out. The hyoid bone is located at the base of the tongue, has multiple muscles attached to it, and stabilizes the tongue and throat during swallowing. Its central location puts it in the vicinity of many important structures. Although it is not close to the trachea as implied by one practitioner. Pain in the area of the hyoid may be caused by the attached muscles, the styloid bone, the carotid artery, the tongue, etc. Most of these would likely be due to an inflammatory process most likely treatable by a course of a strong non-steroidal anti-inflammatory drug. Given the time-course of this problem, this has likely been tried. One caveat would be to ensure that an adequate trial of multiple different medications be tried. One medicine that works for one patient may not work for the next. Also, it may take weeks to fully evaluate one medication, as the dosage is increased to reach a therapeutic level. The hyoid may have been damaged by trauma. A misalignment can cause a click and pain with swallowing. This can easily be diagnosed with a CT scan. The history of neck trauma was not given. The symptoms of hoarseness and neck pain may also be caused by muscle tension dysphonia, a voice disorder that is usually caused by an original insult to the vocal cords. The person then (consciously or unconsciously) tries to compensate by straining the voice and in so doing, causes muscle tension. This causes the pain and further voice problems, and a cycle of worsening voice and increasing tension develops. This should be evaluated by an otolaryngologist specially trained in voice disorders (a laryngologist) and/or an experienced speech pathologist. Carotidynia, or pain of the carotid artery, can also cause neck pain. Usually there is tenderness to palpation in the area of the carotid artery. There is some controversy with the diagnosis, but it is felt to be a benign inflammation of the carotid or adjacent tissue. It is treated with anti-inflammatory medications as noted above. An enlarged styloid process, at the base of the skull can also cause the symptoms noted. The styloid process is directly attached to the hyoid bone by the stylohyoid muscle and ligament. Eagle's Syndrome is a constellation of pharyngeal pain, otalgia (ear pain), dysphagia (problems swallowing), and a globus sensation (the feeling of a foreign body stuck in the throat) caused by the enlarged styloid or a calcified stylohyoid ligament. The theory is that a prior tonsillectomy may cause scarring in the area of the glossopharyngeal nerve causing a neuralgia, or an enlarged styloid process may impinge on the carotid artery causing the pain (carotidynia) and sometimes syncope (feinting). Neuralgias can also cause vague pain syndromes. The various neuralgias are usually a diagnosis of exclusion--other diagnoses have been ruled out leaving neuralgia as a more likely cause. Imaging should verify that the inciting nerve (if identifiable) is not being impinged upon by another process such as neoplasm or infection that can cause nerve excitability and aberrant pain sensations. Neuralgias are treated with several medications that help to modulate nerve impulses. Gabapentin, amitriptyline, and Carbamezapine are several that can be used. As with the anti-inflammatory medications, a full trial of these can take a long time. One dose should be tried for several weeks before elevating the dose in an incremental fashion to a therapeutic level. This may lead to patient frustration and resistance to continuing with a treatment they feel may not be working even though an adequate trial has not yet been performed. The differential diagnosis of neck pain is large. A small sample of some of the more common causes is listed. The hunt for the real diagnosis and thus the proper treatment requires patience by both the doctor and the patient until successful.
Michael J Wolfe, MD
College of Medicine
University of Cincinnati