Association of a globus sensation with esophageal diseases

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.

Pharyngeal Versus Esophageal Stasis: Accuracy of Symptom Localization

Purpose The purpose of this article was to determine whether patients who complain of bolus stasis are accurate at localizing bolus stasis as measured by a videofluoroscopic swallowing study with an esophagram. Method This study used a prospective analysis of outcomes data from the University of Wisconsin-Madison Voice and Swallow Outcomes database in patients with complaints of bolus stasis who completed the combined videofluoroscopic swallowing study and esophagram to determine the accuracy of bolus stasis localization. Results Dysphagia evaluation was completed in 301 patients with complaints of bolus stasis. Patients with complaints of bolus stasis in the throat (i.e., pharynx and cervical esophagus) were less accurate at localizing bolus stasis than patients with complaints in the thoracic esophagus (p < .001). Esophageal stasis was the most common finding regardless of complaint location. Conclusion Patients are poor at localizing bolus stasis, and esophageal stasis is common in patients who complain of pharyngeal stasis. This work supports a comprehensive evaluation of both the pharynx and the esophagus for patients with complaints of bolus stasis in the throat. Future research should focus on identifying symptom profiles that could lead to targeted swallowing evaluations based on patient history and complaint.

Globus: Current Concepts and Dilemmas

Globus is an area of interest for many medical specialists including otorhinolaryngologists, gastroenterologist, allergists, and psychiatrists. It may be caused by an organic disease, but it is not uncommon that an underlying etiology remains unidentified even after a full workup has been performed. Patients who suffer from globus usually visit several physicians from different specialties without finding a solution for their symptoms. Identifying the underlying cause of globus is not always a simple task; therefore, structural or functional abnormalities of the thyroid, larynx, pharynx, and esophagus should be investigated. Gastroesophageal reflux disease is commonly considered to be the underlying cause after being identified in an otorhinolarygeal (ear, nose, and throat) evaluation, which is usually the first diagnostic step. In the last few years, an inlet patch in the proximal esophagus has been shown to be associated with globus, and its elimination has resulted in symptom resolution in some patients. Finally, globus can be associated with psychiatric disorders as well as oropharyngeal hypersensitivity that could be either chemical or mechanical. Treatment is directed toward an identified organic cause; in those with a functional disorder, the mainstay of therapy includes neuromodulators and psychiatric/psychological interventions.

Pathophysiology and treatment of patients with globus sensation--from the viewpoint of esophageal motility dysfunction

"Globus sensation" is often described as the sensation of a lump in the throat associated with dry swallowing or the need for dry swallowing, which disappears completely during eating or drinking and for which no organic cause can be established. Due to the uncertain etiology of "globus sensation", it remains difficult to establish standard treatment strategies for affected patients. Lately most attention has been focused on gastroesophageal reflux disease and several reports have indicated that there is a close relationship between esophageal acid reflux and globus sensation. Nowadays, empirical therapy with a high dose of a proton pump inhibitor (PPI) is considered to be indicated for patients with globus sensation, after excluding organic diseases such as pharyngeal cancer, Zenker's diverticulum, or thyroid enlargement. If patients are nonresponsive to PPI therapy, evaluation of esophageal motility should be done. In our recent study, 47.9% had abnormal esophageal motility, with the most common esophageal motility abnormality being an ineffective esophageal motility in PPI-resistant patients with globus sensation. This suggests that prokinetics alone or adding prokinetics to PPI should be the treatment to be considered, although few studies have investigated the efficacy of prokinetics in the treatment of patients with globus sensation. If patients without any esophageal motility dysfunctions are nonresponsive to PPI therapy, either cognitive-behavioral therapy, anti-depressants, or gabapentin could be helpful, although further well-designed, randomized controlled large-scale studies will be necessary to determine the effectiveness of each treatment strategy on patients with globus sensation.

The complexity of globus: a multidisciplinary perspective

Globus is a topic of interest for many specialties including otorhinolaryngology, gastroenterology and psychiatry/psychosomatic medicine, but, although many hypotheses have been suggested, key questions about its aetiology remain. This Review provides an overview of the extensive literature concerning this topic and discusses the quality of the evidence to date. Globus has been associated with oropharyngeal structural lesions, upper oesophageal sphincter disorders, oesophageal disorders, GERD, psychosocial factors and psychiatric comorbidity. However, findings are often contradictory and the literature remains highly inconclusive. Indeed, with the exception of patients with structural-based globus, the Rome III criteria for functional globus only apply to a subgroup of patients with idiopathic globus. In clinical reality, there exists a group of patients who present with idiopathic (nonstructural) globus, but nevertheless have dysphagia, odynophagia or GERD-exclusion criteria for globus diagnosis according to Rome III. The symptomatology of patients with globus might be broader than previously thought. It is therefore crucial to approach globus not from one single perspective, but from a multifactorial point of view, with focus on the coexistence and/or interactions of different mechanisms in globus pathogenesis. This approach could be translated to clinical practice by adopting a multidisciplinary method to patients presenting with globus.

Comparative study of flexible nasoendoscopic and rigid endoscopic examination for patients with upper aerodigestive tract symptoms

Introduction:

The objective of the current study was to compare the outcomes of rigid endoscopic procedures with those of pre-operative flexible nasoendoscopy.

Methods:

A total of 253 patients who had undergone rigid endoscopic examination under anaesthesia between 6 January 2010 and 31 August 2011 were identified. Their clinical, surgical and histological records were evaluated.

Results:

A total of 213 patients had a flexible nasoendoscopic procedure performed and recorded pre-operatively, and 82 in this cohort had a specific lesion or area of concern identified. There were 21 confirmed malignant biopsy results, the majority of which were squamous cell carcinoma. No patient with a negative pre-operative endoscopy had a malignant lesion discovered on endoscopic biopsy. The sensitivity and specificity of pre-operative nasoendoscopy were 100 per cent and 66.3 per cent, respectively.

Conclusion:

Diagnostic rigid endoscopic examination of the upper aerodigestive tract remains an important tool for excluding malignancy in high-risk patients, but is an unnecessary procedure in those low-risk patients with normal pre-operative findings.

Management of globus pharyngeus

Globus pharyngeus is a common ENT condition. This paper reviews the current evidence on globus and gives a rational guide to the management of patients with globus. The aetiology of globus is still unclear though most ENT surgeons believe that reflux whether acidic or not plays a significant role. Though proton pump inhibitors are used extensively in practice, there is little evidence to support their efficacy. Most patients with globus can be discharged after simple office investigations. The role of pepsin-induced laryngeal injury is an exciting concept that needs further study. Given the benign nature of globus pharyngeus, in most cases, reassurance rather than treatment or extensive investigation with rigid oesophagoscopy or contrast swallows is all that is needed. We need more research into the aetiology of globus.