Work-up of globus: assessing the benefits of neck ultrasound and videofluorography

Efficient management of benign laryngeal symptoms in an endoscopy outpatient clinic

Objectives

A globus and thick mucus in the throat are common reasons for referral to an ear, nose, and throat (ENT) specialist. ENT outpatient appointments focus on nasolaryngoscopy examinations, patient education, and reassurance. An endoscopic outpatient clinic (EOC) was established to efficiently manage patients with benign laryngeal symptoms.

Methods

Patients referred between February 2022 and June 2023 due to a globus and/or thick mucus in the throat were immediately contacted via post. The contact letter included patient education about the potential underlying reasons for their symptoms and self-care instructions. A 15-min outpatient visit was scheduled for an ENT examination and nasolaryngoscopy. Patients completed a questionnaire about their current symptoms and whether they had followed the self-care instructions just before visiting the EOC and 1-month following their appointment.

Results

In total, 203 patients examined in the EOC were included in the study. Before the EOC visit, most patients (89.2%) considered the information letter useful, it relieved concerns in 44.2% of patients, and 73.2% patients had already followed the self-care instructions. After the 1-month follow-up period, symptoms diminished significantly (p < .001).

Conclusions

Instructions for self-care and encouragement relieved concerns among patients with benign laryngeal symptoms. Moreover, symptoms improved significantly after a 1-month follow-up period.

Level of evidence

4.

The Development of Head and Neck Cancer in Patients with the Isolated Complaint of Globus Pharyngeus

OBJECTIVES

Globus pharyngeus (GP) is a perplexing problem that accounts for 4% of referrals to otolaryngologists. Workup can be extensive and may not be definitive in terms of etiology. The concern that lingers is that of a subtle cancer, which can prolong anxiety and increase testing cost. The aim of this study was to identify the incidence of head and neck cancer (HNC) in patients diagnosed with GP.

METHODS

Longitudinal data were captured from two academic institutions, identifying patients with a new diagnosis of globus pharyngeus in 2015. The patient cohort was tracked for at least 4 years to assure follow-up and ability to determine if a HNC developed. Additional demographic data was also collected to determine most common consults, treatments, and testing employed.

RESULTS

Excluding patients with previous diagnosis of HNC, 377 patients were identified who presented with GP in 2015 that had at least 4 years of follow-up. Demographics were predominantly women (64.65%), with a mean age of 56.48 years at diagnosis, and the most common provider specialty on the first visit was otolaryngology (39.52%). Four patients ultimately developed HN cancer, for an overall incidence of 1% for the 4-year period of 2015-2019.

CONCLUSIONS

Given the long-term follow-up of this population, the overall incidence of developing a head and neck cancer, with a presenting symptom of globus, is low. This is the largest study to date to report the percentage of patients endorsing GP to then subsequently develop HNC. This helps otolaryngologists to reassure patients who have a normal comprehensive exam, flexible endoscopy, and targeted studies.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1147-1154, 2024.

The Water Swallow Test and EAT-10 as Screening Tools for Referral to Videofluoroscopy

BACKGROUND

Videofluoroscopy (VFS) is the gold standard in evaluating dysphagia. Water swallow tests (WST) and the Eating Assessment Tool (EAT-10) are commonly used in dysphagia screening. We aimed to determine the feasibility of WST and EAT-10 as screening tools for referral to VFS.

METHODS

Patients (n = 150, median age: 70.0 years, range: 19-92 years, 58.7% female) referred to VFS completed the WST and EAT-10 before the examination. In the WST, we evaluated both the qualitative parameters (coughing, possible change in voice) and quantitative parameters (average drinking bolus size, swallowing speed). Correlations of EAT-10 total scores and WST parameters to the VFS findings were analyzed both individually and combined.

RESULTS

In the WST, the most specific (89.7%) predictor of normal VFS findings was the absence of coughing, and the most sensitive (79.1%) parameter to predict abnormal findings was a bolus size of ≤20 mL. Using a combination of coughing and a bolus size ≤20 mL (simplified WST), the sensitivity of predicting abnormal findings increased to 83.5%. The most sensitive (84.6%) predictor of penetration/aspiration was failing any parameter in the WST. Lack of coughing indicated an absence of penetration/aspiration with an 82.5% specificity. Swallowing speed or combining the EAT-10 results with the WST results did not enhance the sensitivity or specificity of the WST for predicting the VFS results.

CONCLUSIONS

Coughing and average drinking bolus size are the most important parameters in WST when screening for referral to VFS, whereas the swallowing speed does not seem to be useful. The WST is superior to EAT-10 in predicting VFS findings.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1349-1355, 2024.

Gastrointestinal Ultrasound in Functional Disorders of the Gastrointestinal Tract - EFSUMB Consensus Statement

Abdominal ultrasonography and intestinal ultrasonography are widely used as first diagnostic tools for investigating patients with abdominal symptoms, mainly for excluding organic diseases. However, gastrointestinal ultrasound (GIUS), as a real-time diagnostic imaging method, can also provide information on motility, flow, perfusion, peristalsis, and organ filling and emptying, with high temporal and spatial resolution. Thanks to its noninvasiveness and high repeatability, GIUS can investigate functional gastrointestinal processes and functional gastrointestinal diseases (FGID) by studying their behavior over time and their response to therapy and providing insight into their pathophysiologic mechanisms. The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) has established a Task Force Group consisting of GIUS experts, which developed clinical recommendations and guidelines on the role of GIUS in several acute and chronic gastrointestinal diseases. This review is dedicated to the role of GIUS in assisting the diagnosis of FGID and particularly in investigating patients with symptoms of functional disorders, such as dysphagia, reflux disorders, dyspepsia, abdominal pain, bloating, and altered bowel habits. The available scientific evidence of GIUS in detecting, assessing, and investigating FGID are reported here, while highlighting sonographic findings and its usefulness in a clinical setting, defining the actual and potential role of GIUS in the management of patients, and providing information regarding future applications and research.

The assessment and management of globus pharyngeus

Globus is the sensation of a foreign body in the throat. Investigation and management of patients with globus is widely variable. Most investigations yield negative results yet incur varying patient morbidity and healthcare costs, while malignancy is vanishingly rare in the absence of red flag symptoms and ear, nose and throat examination findings. History taking is key and can help to identify possible causative pathology, directing further investigations and management if necessary. Treatment of globus mainly centres on patient reassurance and counselling, and may include reflux management, neuromodulation, or speech therapy in selected cases, and treatment of any identified cause.

ESNM/ANMS Review. Diagnosis and management of globus sensation: A clinical challenge

Globus is a non-painful sensation of a tightness or a lump/foreign body in the throat that is not associated with dysphagia and may actually improve during meals. While several otorhinolaryngologic, thyroid, and esophageal disorders have been linked to globus, cause-and-effect relationships are difficult to establish. Consequently, though part of the evaluation, objective otorhinolaryngologic and esophageal testing is often negative. The presence of alarm symptoms, particularly pain, weight loss, dysphagia, or odynophagia is indications for objective testing. A diagnosis of idiopathic globus requires exclusion of pharyngeal, laryngeal, and esophageal disorders with laryngoscopy, endoscopy, high-resolution manometry, barium radiography, and/or ambulatory reflux monitoring. A trial of acid-suppressive therapy may be reasonable in the absence of alarm symptoms, especially if concurrent reflux symptoms are identified. Ablation of heterotopic gastric mucosa in the proximal esophagus has been reported to improve globus symptoms. Beyond these specific approaches, further management of idiopathic globus consists of reassurance, neuromodulators, and complementary approaches. Globus has a benign course with no long-term consequences, and the overall prognosis is good as the magnitude of symptoms may decline over time.

A prospective cohort study of 122 adult patients presenting to an otolaryngologist's office with globus pharyngeus

OBJECTIVES

To investigate the epidemiology of globus pharyngeus in adult patients presenting to the otolaryngologist's office. Also, the predictors of persisting symptoms, prevalence of anxiety and the effect of clinical assessment were analysed.

DESIGN

This was a prospective cohort study. Follow-up was carried out using a postal questionnaire.

SETTING

One otolaryngologists' office comprising three medical doctors.

PARTICIPANTS

A total of 122 consecutive globus patients presenting to one otolaryngology office in a 1-year period.

MAIN OUTCOME MEASURES

Globus incidence, gender and age distribution, predictors of persisting symptoms and the patient's health-related concerns.

RESULTS

3.8% of first-time visits were regarding globus. The mean age was 48 years [range 20-88 years], and a female predominance was found (ratio 1.49). Eighty-four per cent experienced anxiety, mainly due to fear of cancer. The most common pathological findings were reflux (15.6%) and post-infectious inflammation (10.6%). 21.4% of questionnaire responders reported full remission of their symptoms. Three predictors regarding symptom persistence were identified: male gender (OR 1.52), smoking (OR 3.4) and difficulties in breathing (OR 8.7). Patients with concomitant foreign body sensation were less likely to have persisting symptoms (OR 0.42). No cases of malignant disease were encountered. 94.7% was reassured by the office visit.

CONCLUSION

The incidence of globus is 3.8% in the otolaryngologist's office. Female gender and concomitant foreign body sensation were predictive for presenting to the clinic even if symptom remission had occurred. Male gender, smoking and self-perceived breathing difficulties were predictive for persisting symptoms. Globus is an anxiety-causing symptom, but reassurance is provided by clinical examination by the otolaryngologist.