Funnily enough, I had never heard the phrase either until a year or two ago — it is one of those glib descriptive names that has now stuck.
But although the name is new, most doctors have known about this condition for some time — and please be assured, although it is annoying it is not serious.
Nutcracker oesophagus is a malfunction of the muscles in the oesophagus, also called the gullet.
When you swallow, the food does not simply travel by gravity down from your mouth to your stomach, but instead it is massaged down by a series of co-ordinated muscle contractions, called the peristaltic wave.
Sometimes this process becomes faulty, for a variety of reasons, in turn leading to disorders such as nutcracker oesophagus.
Here the gullet contracts too tightly, causing problems with swallowing, such as food sticking in the throat — or chest pain.
It’s not clear why you should have started to experience this after attacks of gastroenteritis (an infection of the stomach or bowel usually caused by food poisoning or norovirus), though I wonder if you are suffering a type of post-infection irritable bowel syndrome. In your case, it’s only the gullet that is affected.
The condition is diagnosed using an endoscope (a thin flexible tube with a camera on the end) or a test called a barium swallow, where a special drink is swallowed and then tracked with X-ray.
If these prove abnormal, then doctors use a swallowable pressure monitor, which measures pressure in the lower 10cm of the gullet.
CONTACT DR SCURRTo contact Dr Scurr with a health query, write to him at Good Health Daily Mail, 2 Derry Street, London W8 5TT or email drmartin@dailymail.co.uk — including contact details.Dr Scurr cannot enter into personal correspondence.His replies cannot apply to individual cases and should be taken in a general context.
The pressure here can be very high as the gullet suddenly closes — hence the term nutcracker evolved as a description.
Doctors are not agreed on how to treat the condition, partly because the symptoms are so variable.
But if you suffer from recurrent bouts of pain, drugs such as diltiazem can help (these are usually used to relax muscle elsewhere in the body, such as the walls of tiny arteries, and hence normally used for high blood pressure); another option is low-dose imipramine — when used at higher doses this works as an antidepressant, but at low doses it affects the nerves responsible for the muscle spasms.
If the problem is not pain, but difficulty with swallowing or a sensation of food becoming stuck, then the diltiazem is also a good option.
However, medication is not necessary if the symptoms can be tolerated, and in many patients the episodes gradually fade away.
For the past 18 months I have had a permanently runny nose. Three antibiotics failed to clear it, and a recent investigation, using a camera, did not find any abnormalities. My ears now feel ‘tight’ and my worry is that the bug has now travelled there. Roy Brown, Derbyshire.Your story is that of chronic rhino-sinusitis, an inflammatory condition of the nose and sinuses.
Symptoms are nasal discharge — as you have experienced — but there can also be blockage, facial pain and a reduced sense of smell.
Although it cannot be cured for certain, the aim of treatment is to reduce the inflammation and swelling of the lining of the nose and sinuses to improve ventilation and reduce the mucus discharge.
Thanks to the camera investigations it’s clear the problem is not nasal polyps or any other growth or worrying abnormality in the sinuses. So this is all about dealing with the inflammation of the lining.
Washing out the airways with a salt solution — a so-called alkaline nasal douche — can help reduce inflammation and rinse away irritants.
The salty wash should be used prior to any other nasal medications being introduced.
It is made by mixing a teaspoon of salt with a teaspoon of baking soda in a pint of water. Store in a clean jar or bottle and renew every week.
Topical steroids in the form of nasal sprays or nose drops are the mainstay of treatment. This type of medication must be prescribed by your GP or specialist.
It’s important to understand that this condition is not simply a persisting bacterial infection.
An infection might have been the original trigger, but you now have chronic inflammation and the goal is to suppress that inflammation.
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This is because the ongoing mucus build-up may make you more prone to infection (because bugs can begin to thrive in the mucus, and the mucus can also interfere with our natural immune mechanisms in the nose).
That’s why if the symptoms seem to become worse you must consult a doctor to assess whether an antibiotic is needed.
I understand your worry that persisting infection may be damaging your ears: the middle ear cavity (containing the ear drum) is connected to the nose and sinuses via a thin tube that may also be clogged with sticky mucus, but hopefully the strategy I have described will help ease this.
The first step is to start the alkaline nasal douche to wash the mucus from your nose; this will cleanse and moisturise the passages and is known to improve the function of the cells that line the airway.
Do this two or three times each day.
After some weeks, ask your GP to consider steroid drops, asking to be taught how to apply these in the head down position.
There is a fair chance that within months your plight will be much eased.
By the way . . . Penny-pinching costs patients’ livesLast week, I lamented the failure of my profession to change patients’ behaviour — specifically, smoking, drinking and overeating.
This followed reports of the UK’s shocking performance in league tables comparing life expectancy at birth.
Despite the NHS apparently being the envy of the world, we are 12th out of 19 countries.
It’s not just patients’ behaviour that’s to blame, but also what I call the practice of mean medicine.
When a patient comes in with a bit of indigestion he’s often sent away with a prescription for an antacid to see how he goes, rather than sent for costly investigative scans.
Bad GPs get it wrong, taking their mean medicine short cuts. My worry is for the ones in the middle - the majority (file picture)The hope is the patient will soon come back if he or she is not better. But what if that patient is the one with stomach cancer? This is what I mean by ‘mean medicine’.
I was recently asked to advise on the medical notes of someone who’d died of widespread colon cancer after seeing his doctor 13 times in two years.
After two years of abdominal pain he was diagnosed with terminal colon cancer when his friends almost carried him into A&E.
His GP, who didn’t bother with even basic tests such as weighing him, had said taking up swimming would help this man’s back pain (which was due to the cancer spreading to his liver and spine).
But he was so weak that when he did go swimming he couldn’t get out of the pool and his companions had to lift him out and take him to hospital.
Of course, we can all come up with similar bad stories, and we never hear the good stories: good GPs, intuitive and diligent, usually get it right.
Bad GPs get it wrong, taking their mean medicine short cuts. My worry is for the ones in the middle — the majority.
They are the GPs who are under pressure because they’re forced by the system to practise meanly.
This means avoiding referring patients for investigations to save money, and that in turn means late diagnosis.
This will become even more of an impossible situation when the NHS reforms come into effect in April — GPs will be disciplined for profligacy, yet will also be in charge of the cheque book and responsible for commissioning the care.
And with the pressure to reduce referrals and save cash comes the cutting of corners, and not just expensive ones.
There is less time to spend with patients — who, meanwhile, have no guarantee of seeing their own GP with the continuity of care that provides.
Careful medicine involves listening, history taking, clinical examination, and basic simple tests (such as weighing a patient); investigations then follow.
But these days even diligent history taking and thoughtful examination get missed.
So we end up with ever lower standards — and mean medicine that can cost lives.
