Hiccups and Laryngospasm

So one day I was having some bad hiccups... you know, the obnoxious kind complete with strangled noise and chest jerks.

However, this experience unlike the numerous prior episodes of hiccups triggered an intellectual brainstorm about breathing and stridor in general.

FACT:
Hiccups (aka singultus) are due to brief, intermittent, and involuntary diaphragm contractions against a closed glottis. For the layperson, this means during a hiccup:

• Your body takes a quick breath inwards (inhalation)
• Your body brings the vocal cords together
• Both above actions occur simultaneously, involuntarily, and briefly 

Which brought me to consider another disorder called laryngospasm which is the most severe form of vocal cord dysfunction. In this particular condition, the vocal cords come together involuntarily just as in hiccups... BUT, it may last for seconds to minutes while the breathing is still voluntary. At worst, it results in complete airway obstruction causing a loud high-pitched squeal called stridor (check out this movie below). Click here for more information about this condition.



FACT:
Laryngospasm is due to sustained and involuntary vocal cord closure WHILE the person voluntarily tries to breath. For the layperson, this means during a laryngospasm attack:

• Your body tries to breath voluntarily
• Your vocal cords involuntarily closes for a sustained period of time
• The above actions occur simultaneously

So... when you get down to it, the only difference between hiccups which is common and afflicts many people and laryngospasm which is rare is: 1) how long it lasts for and 2) whether the diaphragmatic movement is voluntary or involuntary.

Which got me thinking... is there actually a medical condition that is BOTH a hiccup and laryngospasm at the same time?

In fact, there is... though I must preface by saying there has been only one case report (that I'm aware of) of this super-rare condition called "Diaphragmatic Flutter with Stridor."

Reported back in 1995, the journal Chest reported a 13 years old girl who presented with rapid stridulous panting that occurred only during inspiration while awake (symptoms disappeared while asleep). Laryngoscopy showed an abnormal closed glottis. ECG noted noncardiac electrical activity due to involuntary diaphragmatic contractions occurring at a rate of 200/min. Fluoroscopy of her diaphragm revealed rapid myoclonic contractions of the left hemidiaphragm.

In essence, she was "hiccuping" 200 times per minute while having a sustained laryngospasm attack. The suffering this child and her family must have gone through must have been unbelievable and I'm sure tracheostomy must have been entertained at some point.

Treatment (cure) ultimately was achieved by crushing the patient's left phrenic nerve.

So let's take a look at all three conditions in table format:

	Diaphragm Contraction	Vocal Cord Closure	Timing
Hiccups	Involuntary	Involuntary	Brief
Laryngospasm	Voluntary	Involuntary	Sustained
Diaphragmatic Flutter	Both	Involuntary	Sustained

The common theme between all three disorders is the involuntary vocal cord closure resulting in airway obstruction. The variation in presentation is utterly dependent on whether the diaphragm contraction is involuntary or not and how long the "attack" lasts for.

References:
Diaphragmatic Flutter Presenting as Inspiratory Stridor. 10.1378/chest.107.3.872 CHEST March 1995 vol. 107 no. 3

Laryngospasm and Other Forms of Vocal Cord Dysfunction. Fauquier ENT.

Burning Tongue or Mouth Syndrome Due to Magnesium Deficiency?

Patients with burning mouth syndrome (BMS) have two major findings: one, burning sensations in their mouth and two, no anatomical changes present in their mouth to relate to this burning.

Dr. Henkin and colleagues at the Center for Molecular Nutrition and Sensory Disorders have clinically distinguished two major groups of patients with BMS. One group has burning limited only to their tongue – called GLOSSOPYROSIS. The other group has burning in their entire mouth, including their tongue, lips, palette, gums and pharynx – called OROPYROSIS. They have recently been able to distinguish these two patient groups biochemically.

Patients with GLOSSOPYROSIS have lower levels of magnesium in their red blood cells (erythrocytes) than do patients with OROPYROSIS or normal subjects.

Patients with GLOSSOPYROSIS have lower levels of magnesium in their parotid saliva than do patients with OROPYROSIS or normal subjects.

However, serum levels of magnesium and serum erythrocyte and saliva levels of calcium are similar in patients with GLOSSOPYROSIS, OROPYROSIS or in normal subjects.

These results suggest that patients with GLOSSOPYROSIS are magnesium deficient.

These findings does suggest magnesium supplementation to reverse the magnesium deficiency may be of benefit in patients with GLOSSOPYROSIS.

Courtesy of Dr. Robert Henkin of the Center for Molecular Nutrition and Sensory Disorders.

Reference:
Biochemical differences in parotid saliva distinguish patients with glossopyrosis from those with oropyrosis: Are there also neurochemical differences? The FASEB Journal. 2011;25:857.4

Lemierre's Syndrome on CT Scan

Lemierre's Syndrome is a constellation of signs involving the bacteria Fusobacterium necrophorum. The syndrome usually begins with tonsillitis that progresses to an infected clot in the adjacent jugular vein. Bits of the infected clot break off and spread throughout the body spreading the infection. If it gets bad enough, sepsis may occur.

Here is a CT scan showing the key sign of a clotted off jugular vein indicating Lemierre's syndrome (red arrow). A normal appearing jugular vein is indicated by the blue arrow.