Clicking in the Throat Cinematic Fiction Or Surgical Fact?

CLINICAL NOTE Clicking in the Throat Cinematic Fiction or Surgical Fact?

Marshall E. Smith, MD; Gerald S. Berke, MD; Steven D. Gray, MD; Heather Dove, MA; Ric Harnsberger, MD

he complaint of a clicking in the throat when swallowing is uncommon but very dis- comforting and painful for those who experience it. It is such an unusual complaint that symptoms may be dismissed as psychogenic because a cause for the problem may not be readily apparent. We present a series of 11 cases in which all patients had an Taudible clicking or popping noise in the throat associated with neck and throat pain when swallowing or turning the neck. The most helpful diagnostic procedure was careful examination and palpation of the neck while the patient swallowed to localize the side and source of the clicking. Laryngeal computed tomographic (CT) scans helped in some cases to demonstrate thyroid- cartilage and/or vertebral body asymmetry. Each case was treated with surgery of the neck and larynx to trim the portion of the thyroid cartilage causing the clicking. In most cases the superior cornu of the thyroid cartilage projected posteriorly and medially. Surgery was successful in all cases to eliminate the symptoms. Though an uncommon complaint, our experience suggests that the clicking throat is a surgically treatable problem. Arch Otolaryngol Head Neck Surg. 2001;127:1129-1131

In the 1944 movie Up in Arms, the actor ing sensation in the throat when swallow- Danny Kaye, in his motion picture de- ing. It was frequently painful. When the but, plays a hypochondriac who finds all cause was identified and surgically cor- sorts of ailments in himself and others. De- rected, the symptoms were eliminated. spite his protests of illness, he is drafted into the army. In one scene, while he is DATA AND RESULTS off duty on an outing with his compan- ions, he confronts a street vendor, ex- The patient series is given in the Table, claiming, “What’s that clicking in your which summarizes the patient com- throat?” The joke is repeated in several plaints and procedures performed. This in- other scenes throughout the movie. This cludes patients from 2 institutions: 7 from symptom, whether real or imagined, is so the University of Utah, Salt Lake City, and unusual that the famous comedian appar- 4 from the University of California, Los An- ently found it an amusing addition to his geles (UCLA). Five patients noted the on- script. However uncommon or unbeliev- set of their symptoms at a traumatic event, able, we have found that this symptom can including 2 motor vehicle crash–related indeed occur in association with swallow- neck injuries, 1 sledding crash–related in- ing, throat pain, or turning the neck. jury, 1 wrestling-related injury, and 1 in- We describe a series of 11 patients jury from a fall. Two patients noticed their who presented with a peculiar distur- symptoms after intubation for a surgical bance of swallowing and/or throat pain. procedure (1 after microlaryngoscopy and They frequently complained of a clicking 1 after cesarean section). or popping noise and a rubbing or grind- Figure 1 shows the locations of the clicking and portion of thyroid cartilage From the Division of Otolaryngology–Head and Neck Surgery, National Center for operated on in this series. The main source Voice and Speech (Drs Smith and Gray and Ms Dove) and the Department of Radiology of clicking was the superior cornu, which (Dr Harnsberger), University of Utah School of Medicine, Salt Lake City; and the was generally displaced posteriorly and Division of Head and Neck Surgery, University of California, Los Angeles, UCLA medially. Two patients had bilateral symp- School of Medicine (Dr Berke). toms, and both sides were operated on.

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Patient No./ Location Prior Neck Sex/Age, y Type of Symptoms (Duration, mo) of Symptoms Trauma Procedure Outcome 1/F/37 Clicking when swallowing, throat pain (5) R neck No R SCE Complete resolution 2/F/27 Clicking when swallowing, neck pain (9) Mid neck Yes Trim superior edge of the thyroid lamina Complete resolution 3/M/18 Clicking when swallowing, neck pain (24) L neck Yes L SCE Complete resolution 4/F/39 Clicking when swallowing, neck pain (12) Bilateral neck, No Bilateral SCE, posterior edge thyroid Complete resolution RϾL ala excision (staged) 5/M/25 Clicking when swallowing, neck pain (12) Bilateral neck No Bilateral SCE Complete resolution 6/M/29 Throat pain when playing trumpet (12) R neck No R SCE Complete resolution 7/M/36 Odynophagia (6) L neck Yes L SCE Complete resolution 8/F/54 Throat pain, aphonia, odynophonia (8) R neck Yes R SCE Complete resolution 9/F/27 Throat, neck, facial pain (9) R neck Yes R SCE Complete resolution 10/F/51 Throat pain, clicking when swallowing (4) R neck Yes R SCE Complete resolution 11/F/15 Throat pain, clicking when swallowing (24) L neck Yes L SCE, L hyoid trim (staged) Complete resolution

*R indicates right; L, left; and SCE, superior cornu excision.

against vertebral fascia, ulceration of A vertebral fascia, and elongation of the lateral edge or superior edge of thyroid ala. In 1 case, in addition to superior cornu fracture, the greater cornu of the hyoid bone was also frac- tured posteriorly and abutted the vertebral transverse process. The symptoms of clicking in the throat, pain, and/or dysphagia re- solved in all patients. In most patients, immediate resolution of symptoms occurred in the recov- B ery room. Several patients experi- enced a gradual reduction in pain or pressure over 1 to 3 months.

COMMENT

Throat clicking associated with swal- Figure 1. Larynx anatomic sketch with the regions marked where structures were trimmed lowing, neck turning, or neck pain is to alleviate symptoms of laryngeal click. Patients uncommon. A few cases have been had symptoms involving the superior cornu of reported. These reports describe a the thyroid cartilage, the superior cornu and lateral thyroid ala, superior margin of the thyroid varietyofdifferentsourcesoftheclick- cartilage, or the greater cornu of hyoid bone. Figure 2. A, Axial plain computed tomographic ing. In 1 report, a 23-year-old man scan of the larynx in the neutral position reveals an elongated posterior margin of the thyroid with no history of neck trauma com- One patient had clicking of the su- cartilage perched on the anterior surface of a plained of clicking in the throat and perior edge of the thyroid lamina cervical vertebral body transverse process pain in the left thyrohyoid region of against the hyoid bone. One pa- (arrowhead). B, Axial computed tomographic the neck when swallowing over sev- scan with the head turned to right shows the 1 tient with a history of neck trauma thyroid cartilage posterior alar margin has eral months. On physical examina- from a sledding crash had deflec- “jumped” off the transverse process (arrow). tion, the left side of the hyoid seemed tion of both the superior cornu and to ride over the thyroid lamina, and greater cornu of the hyoid bone. clicking, which usually required neck the clicking ceased when the patient At the University of Utah, the turning and/or neck flexion. As we be- swallowed with the neck extended. first 3 patients were operated on un- came more confident of the source of During surgery, a shortened thyrohy- der local anesthesia with intrave- the clicking, general anesthesia was oid space on the left side was found. nous sedation so they could swallow used. In the 4 patients operated on at The superior edge of the left thyroid and identify the source of the click- UCLA, general anesthesia was used cartilage was trimmed, resulting in a ing on the operating table and con- with 1 patient and local anesthesia completeresolutionofsymptoms.The firm resolution of symptoms during with 3. Findings at surgery included findingsreportedinthiscaseareanalo- surgery. While in the supine posi- fracture of the superior cornu, pos- gous to those of patient 2 in the Table tion with the neck extended, the pa- terior displacement of the superior of our series. In most other patients tients had difficulty reproducing the cornu, abutment of the superior cornu in our series, the superior cornu of the

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©2001 American Medical Association. All rights reserved. Downloaded From: http://jamanetwork.com/ by a University of California - Los Angeles User on 08/01/2017 thyroid cartilage was responsible for Results of imaging studies (CT orintubation.Themostcommoncause producingthesymptoms.Othersingle scans) were initially reported as “nor- was an elongated or posteriorly ori- case reports of throat clicking have mal.” After several such studies, a dif- entedsuperiorcornuofthethyroidcar- beenrecentlypublished.2,3 Thesecases ferent technique was performed at the tilage. Based on our experience, we were due to elongation of the greater University of Utah. If the clicking oc- conclude the following: (1) Physical cornu of the hyoid bone rubbing curred when turning the head, a spi- examination is needed, with careful against the vertebrae. Patient 11 had ral CT scan was performed with the palpation of the neck during swallow- a similar abnormality (Table). patient in the neutral position. It was ing and reproduction of symptoms to Clicking larynx symptoms are then repeated with the patient’s head localize the source of the click. Atten- more easily explained in those with turned and during a swallow. This tion should be directed toward the su- a history of neck trauma, as experi- demonstratedtheunderlyingdynamic perior cornu of the thyroid cartilage enced by several of our patients. In cause of the sound (Figure 2). Inter- when symptoms are to the side of the those without such history, the cause pretation of the CT images requires neck and toward overlapping struc- of this phenomenon is less clear. The knowledge of the abnormalities that tures in the thyrohyoid space when occurrence of clicking larynx symp- may cause the clicking sound. The 3 symptoms are in the anterior of the toms suggests that the thyroid carti- abnormalities that were identified on neck. (2) Laryngoplasty is an effective lage structure may, in a subtle way, CT scanning in our series included (1) treatment under local or general an- change shape with age. posteriorelongationofthethyroidcar- esthesia to trim the offending region We found that the most impor- tilage ala, (2) superior elongation of (s) of the thyroid cartilage and/or hy- tant assessment in these cases was the superior cornu of the thyroid car- oid bone responsible for the clicking. careful physical examination. The lo- tilage, and (3) an asymmetrically large Accepted for publication May 17, 2001. cation of the clicking could be iden- cervical vertebra transverse process. Supported by grant K08- tified by palpation of the neck when DC00132 from the National Insti- the patient swallowed, and elicita- CONCLUSIONS tutes of Health, National Institute on tion of a click or laryngeal crepitus Deafness and Other Communication could occur on side-to-side palpa- Clicking in the throat can be treated Disorders, Bethesda, Md. tion of the larynx. This maneuver surgically.Physicalexaminationisfun- Corresponding author: Mar- may reproduce the throat or neck damentaltoidentifytheclickingsource shall E. Smith, MD, Division of Oto- pain symptoms at the site of the la- so that a treatment procedure can be laryngology–Head and Neck Sur- ryngeal clicking. In those with a thin confidently recommended. Patients gery, 3C-120, University of Utah neck, anterior displacement of the canbereassuredthattheseuncommon School of Medicine, 50 N Medical Dr, thyroid ala on the affected side dur- symptoms are not products of their Salt Lake City, UT 84132 (e-mail: ing a swallow may alleviate symp- imagination or something seen only [email protected]). toms. In patients seen at UCLA, a lo- in movies; they are real and can be suc- cal injection of lidocaine in the cessfully treated. In our series, laryn- region of the superior cornu tem- geal clicking when swallowing was a REFERENCES porarily improved symptoms and bona fide symptom with an identifi- 1. Counter RT. A clicking larynx. J Laryngol Otol. was thought to be diagnostically able cause. It often had associated 1978;92:629-31. helpful. Indirect laryngoscopy did throat pain and dysphagia and was 2. Makura ZGG, Nigam A. The clunking neck. J Laryn- gol Otol. 1995;109:1217-1218. not reveal the cause of the clicking frequently, but not necessarily, asso- 3. Hilali AS, Saleh HA, Hickey SA. Clicking hyoid. in most patients. ciated with prior trauma to the neck J R Soc Med. 1997;90:689-690.

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