Tommy Flannagan: A 47-Year-Old Male With Severe Episodic Throat and Ear Pain

Tommy Flannagan

Tommy Flannagan is a 47-year-old male electrician with the chief complaint of, “I’m getting sharp pains in my throat and ear every time I swallow.” Tommy stated that over the last 3 weeks, he had been having electric shocks that started in the back of his throat and then shot up into his ear. Tommy said that the pain would come out of nowhere and then go away as quick as it came. He said that it seemed like when he coughed or cleared his throat, it would trigger the pain, as did swallowing and sometimes chewing meat. “Tommy, is the pain on both sides or just on one side?” He replied, “It’s always on the left, Doc. It’s never on the right.” Tommy went on to say that he had tried a heating pad and Tylenol, but the pain continued to get worse. I asked Tommy if had ever had anything like this before, and he shook his head no. I asked what made it better, and he said he had been “living off Campbell’s tomato soup” to avoid triggering the pain, but that nothing really worked. I asked how he was sleeping, and he said he had taken to sleeping in his recliner because every time he rolled over onto his right side in bed, it triggered the pain that woke him. Tommy denied any fever or chills.

On physical examination, Tommy was afebrile. His respirations were 16 and his pulse was 68 and regular. His blood pressure was 118/72. His fundoscopic examination was normal. It took some convincing to get Tommy to open his mouth to let me examine his hypopharynx. I noted that Tommy still had his tonsils, but his dentition looked fine, and there was no obvious tumor or mass. When I touched the area just below the left tonsil with the tongue depressor, Tommy immediately cried out in pain and jerked away from me. I was glad that my fingers weren’t in his mouth or he may have bitten them off. “Doc, warn me when you are going to do that again! It’s really bad, and I need to have hold of something.”

When I told him I wanted to take a look at his ears, he went nuts. “Doc, can you put me out before you look? I just don’t know how much more of this pain I can take! It’s horrible, worse than anything you can imagine. I did not know that anything could hurt this bad!” I said, “Let’s start with the right ear and go from there. How about that?” Tommy was reluctant, but said, “Do what you have to do, Doc. I have to get better or I am done for. I am afraid this will hit when I am up on a ladder at work. What did I do to deserve this?” His right ear exam was normal, and with much convincing, I got a quick look at his left ear, which appeared completely normal. His cardiopulmonary examination and thyroid were normal. His abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. His low back examination was unremarkable.

I asked Tommy to point with one finger to show me where it “hurts the most” and with great care to avoid touching his submandibular area, he pointed to a point just below the mandible near the trachea on the left. “Doc, the pain starts way down deep in here—way at the back of my throat here—and it shoots up into my ear. Kinda ironic, isn’t it? Here I am an electrician, and my own body is shocking me.” A careful neurologic examination of the upper extremities revealed that there was no evidence of peripheral or entrapment neuropathy, and the deep tendon reflexes were normal. There were no pathologic reflexes. “One more question, Tommy. When you get the pain, do you ever get lightheaded or feel like you are going to pass out?” Tommy shook his head no and said, “Doc, never anything like that, but when it’s really bad, I think about blowing my brains out. I guess it’s a good thing that I don’t have any guns.” I told Tommy that I was pretty sure I knew what was going on and that we had a lot of treatment options to get on top of this pain. Tommy replied, “From your mouth to God’s ears.”

Key Clinical Points—What’s Important and What’s Not

What Tests Would You Like to Order?

The following tests were ordered:

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  Magnetic resonance imaging (MRI) of the brain with special attention to the brainstem

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  Magnetic resonance angiography (MRA) of the cerebral circulation

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  Electrocardiogram (ECG) with rhythm strip taken when patient triggers the pain

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  Erythrocyte sedimentation rate