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Dr. David
Dr. David, Board Certified MD
Category: Neurology
Satisfied Customers: 42321
Experience:  Experienced physician in Neurology
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I am a 29 year old female that has been experiencing some

Customer Question

Hi, I am a 29 year old female that has been experiencing some weakness in breathing, strained speech at times, and occasional swallowing for about 2 months now . I've been to two neurologists who did EMG's of both limbs and face, a single one near the spine, and two tongue EMG's. I have had two pulmonary function tests which seem to only show a low mep. I have been scoped at the ent who said it looks like I have mild paresis of the left vocal cord and will be seeing a speech pathologist. I also have had a swallow barium test a month ago which looked normal. My concern is with these symptoms I'm worried about bulbar als. I have constant fasciculations in my tongue that have been happening for 2 years but with no atrophy, but for some reason both the tongue EMG's a month apart were normal. I was told tongue fasciculations are rarely Begnin. Should I be worried that this is bulbar als or would the two tongue EMG's and other EMG's showed it despite my symptoms?
Submitted: 2 months ago.
Category: Neurology
Customer: replied 2 months ago.
Also the ent said there was no atrophy in the mouth or palet. The fasciculations of the tongue are constant and are easily seen by any doctor, but I was told that both tongue EMG's were clean as well which makes no sense because they said tongue fasiculations and quivering which is what I have are rarely begnin. I've also have random fasiculations in all other muscles of my body for two months that come and go in location. The breathing difficulty and swallowing seems to wax and wane as well.
Expert:  Dr. David replied 2 months ago.

This is Dr. David

bulbar ALS is very very very very very rare

do you have excessive anxiety symptoms?

excessive anxiety can cause you to have benign fasciculation and twitching of muscles

and also can cause breathing irregularities, strained speech and swallowing symptoms

anxiety can also cause pressure in your throat and chest as well.

it sounds like you have had a lot of testing already.

with your EMG being nromal, you would not have ALS or even early ALS.

fortunately, ALS is a very rare condition.

lack of sleep, dehydration, low potassium and low magnesium levels can also cause fasciculations as well

let me know if you have questions.

Customer: replied 2 months ago.
Well normally no I don't have anxiety, but due to the symptoms I've been dealing with I do feel anxious. I guess I am unclear due to conflicting information about tongue fasiculations rarely being Begnin. However, since my tongue has been constantly fasiculating/ quivering for two years wouldn't the EMG show it. I had first noticed the fascs which didn't even bother me two years ago and I was told it could be caused by long term use of seroquel/ celexa which I had taken for over 10 years for mild anxiety but wasn't ready to wean myself off because of the horrible withdrawals. Could such medication cause the permanent movements? I have been off the seroquel 4 years and celexa one year. Thanks for your insight.
Customer: replied 2 months ago.
Again these are not one of two twitches but constant fasciculations and quivering that both neuro's have seen and tested. I'm more concerned with the trouble breathing with lowered mep on pft, swallowing where I inhale food/ saliva before I'm ready and choke, plus the now strained voice.
Customer: replied 2 months ago.
I was recently given a script by the neuro due the unilateral vocal cord paresis to have a laryngeal EMG which I don't know will also help rule out any bulbar als if there is any.
Expert:  Dr. David replied 2 months ago.

yes, EMG would have shown a neurological problem if you had a neurological disorder.

long term use would not cause movement disorders.

if your voice is normal and swallowing normal, and no vocal cord paralysis, then most likely no bulbar ALS

it sounds like you are letting your anxiety get out of control with worry here.

you may need to go back on your celexa to help decrease anxiety symptoms

or use clonazepam or hydroxyzine to help decrease anxiety symptoms.

regular exercise, meditation, yoga can help decrease anxiety symptoms as well

I would not worry about the fasciculations. but this can be hard to do if your anxiety symptoms are bad.

let me know if you have other questions.

if done for now, please leave positive rating of 3-5 stars so I can get credit for helping you today

we only get credit for helping clients after positive feedback

you can always reach me directly with "a question for Dr. David" in the medicine or oncology categories if you have other questions

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Thanks for using

Customer: replied 2 months ago.
Well that's why I'm worried because my voice is not normal Anymore it's strained and breathy with one vocal cord partially paralyzed , and I sometimes inhale food/ saliva before I am ready, that with the combination of the fasiculations is what has me worried. But you said the EMG's would have shown problems if it were motor neuron related. What else could cause constant quivering/ fasciculations of the tongue? I have been taking klonopin and it doesn't help much. I additionally was diagnosed at Columbia university with autonomic dysfunction/ pots where my heart rate goes to 150 or so from supine to standing after a tilt test.
Customer: replied 2 months ago.
All of this with the levels of maximum expiratory pressure being 57% and maximum voluntary ventilation being 75% below normal and despite full effort gave me worried obviously. If I were not symptomatic and didn't have abnormal ent or pulmonary test with the other issues I wouldn't be worried.
Expert:  Dr. David replied 2 months ago.

it sounds like a lot of this is due to severe anxiety symptoms which most likely have worsned fter you have stopped taking the seroquel and celexa.

you may have to go back on those medications to help decrease anxiety symptoms and symptoms of severe worrying and to help the fasciculations.

pulmonary function testing numbers can be low if you didn't have a strong coach to force you to blow blow blow hard into the machine.

do you smoke? smoking can also cause increased resistance in your lungs as well.

Customer: replied 2 months ago.
No I don't smoke and have always been active. I was told this wasn't anxiety. I of course have anxiety due to the symptoms I'm suffering with vs anxiety for no reason. What I don't understand is how anxiety can cause a partially paralyzed vocal cord, trouble with breathing a low levels on a pft which are used to measure breathing muscle strength, difficult with swallowing, and lack of air to produce a strong voice and the constant tongue fasiculations. Those are all valid symptoms of bulbar motor Neuron issues and I read that no tongue fasiculations that are real fasiculations which I have are begnin. I don't understand how all these symptoms can just be written off as anxiety when they've come on only within two months and are getting worse. And the only thing that showed on the cervical mri was mild stenosis. One neurologist said their EMG showed some radiculopothy of the lower legs and cervical spine, the next one said they didn't see anything and both said the tongue EMG was clean. I just feel desperate for answers because anxiety doesn't cause vocal cord paresis or radiculopothy or stenosis or weakness or fasciulations and no doctor has taken the time to explain what else could be a legitimate cause which wouldn't be just dismissed as anxiety. I was not anxious before these horrible symptoms or abdominal tests. Is there nothing else that could cause these issues?
Expert:  Dr. David replied 2 months ago.

I don't think your vocal cords and partially paralyzed.

anxiety can cause you to have nervousness in your voice, can cause voice tremor, can cause you to swallow frequently, can cause you to have a lump in your throat, can cause you to have dry throat and dry mouth.

your barium swallow study was normal, you didn't aspirate liquids into your lungs. your vocal cords automatically close up when you swallow liquids to prevent liquids from going into your airway

this wouldn't happen if you had paralyzed vocal cords.

Customer: replied 2 months ago.
The ent said and showed me on video when he did a cope of my vocal cords that the left side is weak and only partially vibrates and moves. It's not a tremor in he voice but it feels strained like I don't have enough air to push out the sound and my voice is somewhat hoarse and lowered in volume. I'm not swallowing anymore than usual. I have episodes where my jaw or chewing muscles get weak or I swallow saliva or food before its all the way chewed or without being ready and then it goes down the wrong pipe leaving me coughing for 10 minutes. I understand you think it's anxiety but it seems strange that all those things could be just Labeled as that. I've had general anxiety for half of my life and never had any of these issues. It's as if my muscles are not working or something is misfiring.
Expert:  Dr. David replied 2 months ago.

are you exercising regularly?

you could be out of shape and because of that, not have enough air to push out.

if you are grinding your teeth frequently, this can cause your jaw muscles to be weak.

your EMG testing have been normal.

Customer: replied 2 months ago.
No I'm not exercising regular due to the extreme heart rate. I don't know if I grind my teeth. The one neurologist said they saw radiculopothy in legs and cervical spine. The other said they didn't see anything and both tongue EMG's were normal. However, it doesn't explain the swallowing difficulty, fasics, lowered pft's, and as the ent said paresis of a vocal cord. I feel as if there are findings from different doctors but no one has been able to give me an actual answer or cause. It's very unsettling. If I was not symptomatic and had normal pft's and both normal EMG's where one doesn't say radiculopothy, and a normal ent scope which says abnormal scope on the report due to unilateral left vocal cord paresis, then I would not feel concerned. I've also had a full autoimmune panel done with a positive ANA but everything else was normals. I'm still waiting for a MuSk myasthenia test to come back as it does run in my family.
Expert:  Dr. David replied 2 months ago.

get the myasthenia test and see what it shows

I suspect it will be normal and not show myasthenia gravis.

your symptoms don't point to one neurological condition.

you are picking small findings from any doctor who will find any finding for you

if you continue to do this, you will continue to find findings, but no diagnosis

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