How Does Neuropathy Lead to Lump in Throat or Phlegmy Throat Sensation?

To preface, have you ever been to the dentist and received a novacaine injection prior to a dental procedure? Did you notice that where the injection is performed, it feels as if the area feels really swollen and also you feel like you are drooling... but than when you look in the mirror, there's no drooling and there's no swelling either?

In this dental situation where novacaine got injected leading to a temporary induced neuropathy...  a similar phenomenon can also occur in the throat region due to neuropathy most commonly triggered by a virus or throat-level reflux (LPR). This condition is called laryngeal sensory neuropathy (LSN).

And because the neuropathy occurs in the throat region... a sensation of swollen or lump feeling in the throat (globus) may occur just like the sensation in the face/jaw after getting numbed up for a dental procedure.

Similarly, a mucus phlegmy throat sensation may also occur just like a drooling sensation of the face/jaw after being injected with novacaine.

Such a swollen throat or phlegmy throat sensation can also be temporarily induced in normal patients when the throat gets numbed up with lidocaine or other anesthetic for a surgical procedure.

How is this condition treated?

First and foremost, other non-neurologic etiologies must first be ruled out with medications and extensive testing. Also, triggers that may have led to this neuropathy must be thoroughly addressed as well. Such testing may include allergy testing, specific food avoidance, 24 hour multichannel pH impedance, manometry, etc, etc.

SELSAP is a promising test to evaluate for laryngeal sensory neuropathy.

Once laryngeal sensory neuropathy is confirmed, medications like amitriptyline, neurontin, and tramadol can be tried.

For more information, click here for globus and here for phlegmy throat.

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Why Does EpiPen Have to be Injected into the Thigh?

As any severely food allergic patients know, when suffering from a potentially life-threatening anaphylactic reaction, they need to jab an epinephrine needle into the side of their thigh...

But... why the thigh? Why not the arm like most other shots?

Per AAAAI, there have been 3 anatomic sites investigated to determine which location offers the fastest systemic absorption of epinephrine when injected intramuscularly and/or subcutaneously.

• Intramuscular injection in the upper arm (deltoid muscle) just like a flu shot.
• Subcutaneous injection in the upper arm just like an allergy shot.
• Intramuscular injection in the lateral thigh (vastus lateralis muscle).

Of these sites, the intramuscular thigh injection demonstrated the fastest rise in blood epinephrine.

When dealing with a life-threatening anaphylaxis, you need the speed because if the drug is too slow, the person may die before adequate epinephrine levels are achieved... and the thigh muscle provides the speed whereas the other sites do not.

Why might that be?

It's probably because the thigh muscle is large with lots of blood vessels allowing for multiple points of access for the injected epinephrine to enter into the blood circulation.


References:
Epinephrine absorption in children with a history of anaphylaxis. J Allergy Clin Immunology 1998; 101(1):33-37.

Epinephrine absorption in adults: intramuscular versus subcutaneous injection. J Allergy Clin Immunol 2001; 108(5):871-873.

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Food Allergy Reaction Video

So the other day, I was watching the movie Hitch starring Will Smith and Eva Mendes during which there is this one scene where Hitch suffers an allergic reaction from a food he ate during a dinner date. Watch video.

It's actually a pretty good depiction of a reaction due to a food allergy.

However, given the throat-clearing suggesting airway swelling which extends to his face, he really should have called 911 as this not uncommonly leads to death if the airway swelling is severe enough to obstruct his breathing. Along with facial and airway swelling, his blood pressure probably dropped and his heart rate increased to point he could have passed out due to insufficient blood flow to the brain. Of course, it was a movie and none of that happened, but don't think for a second that benadryl alone is adequate.

It is a little unusual for an adult to have a previously unknown food allergy with this severe a reaction in someone as old as Hitch, but not impossible.

Treatment was appropriately given with benadrylin the movie, but in reality Hitch additionally should have gone to the ER where epinephrine and steroids also would have been administered followed by several hours of observation.

After recovery, he should ALWAYS carry an epipen with him. He should also probably see an allergist to determine what it was he reacted to so that he can avoid it in the future.

On another note, in the movie, Hitch literally chugs down an entire bottle of liquid benadryl and acts drunk from it. That usually wouldn't have happened... rather, he would have gotten extremely drowsy and fallen asleep fairly quickly. However, in some individuals, it might occur.

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"Mouthwatering" Foods May Be a Misnomer?

In the spirit of Thanskgiving where thoughts of food predominate, British researchers have determined that humans are NOT able to produce more saliva by merely thinking of foods whether hungry or not.

This includes looking at pictures of sumptuous foods.

What researchers did determine is that SMELLING foods increased salivary production significantly. Tasting and chewing was even more influential in salivary production.

So at least for humans, unless the food is smelled, tasted, or chewed, mouthwatering just does not happen.

Of note, salivary production was determined by placing cotton pledgets inside the cheeks (saliva produced by the parotid glands) and a suction device under the tongue (saliva produced by the submandibular glands) on healthy volunteers.

Read MSNBC report here.

Reference:
IS THE MOUTHWATERING SENSATION A TRUE SALIVARY REFLEX? Journal of Texture Studies Special Issue: Food Oral Processing - Physics, Physiology, and Psychology University of Leeds, U.K. Volume 42, Issue 3, pages 212–216, June 2011

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