The referral came from a mental health clinic. A woman had been putting the hose of a handheld vacuum cleaner into her mouth, pushing the nozzle toward the back of her throat, and turning it on. She had done this more than once a day for several days. The clinician who examined her found bruising and abrasions throughout her mouth. She was referred to me because her mouth and throat hurt.

The explanation in the chart was that she was trying to remove the devil. I could have stopped there. The behavior was dangerous, and the words sounded like an answer to why she was doing it. But they did not tell me what she was feeling in her throat. The clinician who referred her had recognized the injury and asked for help. I needed to understand the experience that had led to it.

She cooperated with most of my examination. She did not want me to pass a flexible scope through her nose to examine her throat and voice box, so I could not complete that part of the assessment. We kept talking.

I asked her about the devil. She told me he was responsible for a war. I asked what kind of war. “Good against evil,” she said, and evil always won. Then I asked a question that changed the visit: “Where is the war?”

“In my throat.”

She explained that the good guys were above and the bad guys were deep down. She was trying to get the bad guys out. What the chart had summarized as an attempt to remove the devil was also her attempt to reach a particular place in her body.

I asked whether there was fire in the war. Her eyes widened. Yes, she said. The devil had a flamethrower, and she was trying to take it away from him.

I began to wonder whether she was describing a burning sensation in the only language available to her. I could not establish the cause during that visit. The trauma from the vacuum cleaner itself could have contributed to her pain. Reflux was another possibility worth considering. I spoke with her psychiatrist and recommended a trial of acid-suppressing treatment while her care team continued to look after her safety.

Later, her caregivers reported that the war had stopped. She was no longer putting the vacuum cleaner in her mouth.

I want to be careful about what that outcome tells us. I did not measure reflux, and her improvement after treatment does not prove that reflux caused the burning she described. I cannot separate the effect of medication from other changes in her care or from healing after the injuries stopped. What I can say is that her account contained a description of distress in a specific part of her body. Taking the time to ask about it helped us find a way to respond.

Her psychiatrist had recognized the physical harm and made the referral. She later thanked me for spending time with the patient and spoke frankly about how difficult it was to give that much time to every person in her care. I understood. Listening closely is easy to recommend and hard to fit into a crowded clinic. This visit changed what I listen for when a patient’s words do not sound like a medical history.

A patient may describe pain through a story we do not understand at first. The story may coexist with psychiatric illness. The injuries still need care, and the physical sensation still deserves investigation. We have to ask enough questions to learn what the patient means before the words in the chart become the whole diagnosis.

I remember the moment her eyes widened when I mentioned fire. She had been trying to tell us something about her throat. One more question helped me hear it.

Franklyn R. Gergits is a board-certified otolaryngologist and fellowship-trained otolaryngic allergist with a clinical focus in rhinology and airway disorders and more than 30 years of clinical experience. He is affiliated with HonorHealth Scottsdale Shea Medical Center and is the founder of Sinus & Allergy Wellness Center of North Scottsdale.

Dr. Gergits performs in-office balloon sinuplasty, turbinate reduction, NEUROMARK posterior nasal nerve ablation, and Eustachian tube dilation under local anesthesia. He performed the first balloon sinuplasty in Pennsylvania and holds dual Entellus Centers of Excellence certifications.

His recent scholarly work includes “Posterior Sinonasal Syndrome: A Pepsin-Mediated Hypothesis for Chronic Rhinosinusitis” and “The Continuous Mucosal Liquid Layer: A Unified Hypothesis for Airway-Digestive Immune Surveillance, Mucociliary Transport, and Disease Susceptibility.” His ORCID profile is available at ORCID. He also publishes patient education and clinical commentary through the Airway & Sinus Wellness Review and shares updates through Facebook, Instagram, LinkedIn, X, YouTube, and TikTok.