Could someone please give me some advise concerning a problem that I have had for about 9 months. When I swallow, my tonge feels "stiff" on the left side (in the back) and I feel liquids going up the back of the nose (not coming out of the front of my nose). As a result, I am constantly snorting to get the "liquid" back out of my nose. I have been to a doctor who examined my vocal cords and intially said that I had the symptoms of an "incompent palate" however, upon my next appointment he said he was unable to view the same problem and recommended I get my tonsils out (since my left tonsil is huge).
By the way the same doctor also prescribed antibiotics for 28 days but the sensation of liquid in the back of my nose did not stop. Also, I have been tested for allergies and I am only allergic to cats and feathers and I am not exposed to either. I have never had sinus problems like this in my life (I am 33 years old). Any help on this subject would be appreciated!
Answer ---------
The symptoms described are suggestive of nasal regurgitation. Nasal regurgitation usually is related to velopharyngeal (palatal) incompetence whereby the palate fails to completely close off the nasopharynx (the upper extent of the throat located between the back of the nasal passage and the top of the palate) during swallowing or speech.
Velopharyngeal incompetence can occur as a result of congenital disorders; trauma; palatal surgery; or it can be related to neuromuscular dysfunction. Neuromuscular control of palate movement is via a plexus of nerves known as the pharyngeal plexus. The motor component of this plexus is via the Vagus n. (10th cranial nerve) with a small contribution from the trigeminal n. (5th cranial nerve). If these nerves are not functioning properly, palatal incompetence could occur. Bilateral dysfunction of this nerve plexus would be suspicious for a central nervous system disorder. A unilateral or one-sided dysfunction of the nerve plexus would be more likely due to a peripheral disorder (ie a problem with the nerve somewhere along its course after exiting the central nervous system).
The presence of velopharyngeal incompetence involving the entire palate is usually obvious causing easily recognizable speech patterns (known as hypernasality) and significant difficulty swallowing (particularly liquids). Lesser degrees of incompetence, particularly when only certain parts of the palate are affected may cause more subtle symptoms and may be more difficult to diagnose. For example if only one side of the palate were affected, the symptoms and clinical findings may be more subtle.
The diagnosis of velopharyngeal incompetence, particularly if it is unilateral, may require transnasal fiberoptic endoscopy to allow an inspection of the palate movement from above. Additionally, there are certain x-rays known as cine-fluoroscopy that are sometimes used to assess palate function. A more direct way to assess the function of the motor nerves in the palate would be electromyography (EMG).
In regards to the possible association between the symptoms described and a finding of an asymmetrically enlarged tonsil - there may indeed be some association. Significant asymmetry in tonsil size is unusual and may warrant consideration of biopsy. One must be careful to distinguish between true asymmetry in size versus asymmetrical position of tonsils having equal size. Before removal or biopsy of the tonsil, I would investigate the palate function in more detail (at least transnasal fiberoptic endoscopy should be considered and possibly EMG).
--
Steve Dankle, MD
Otolaryngology-Head and Neck Surgery
Milwaukee, Wis
NOTICE: OFCN is not engaged in the rendering of professional medical services. The information contained on this system or any other OFCN system should not supplant individual professional consultation. It is offered exclusively as a community education service. Advice on individual problems must be obtained directly from a professional.
Click here to review
previous Ear, Nose and Throat Clinic consultations