Severe hypertrophy of the base of the tongue in adults

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.

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

Globus patients with normal ear, nose, and throat (ENT) status are a diagnostic challenge. The symptom may be long lasting and cause concern about malignancy, leading to possibly unnecessary further investigation. The aim of the study was to assess whether radiological examinations are useful in globus diagnostics, how often patients suffer from persistent globus, and whether globus patients with normal ENT status develop a malignancy during a follow-up. We reviewed medical records of all 76 globus patients referred to Helsinki University Hospital, Department of Otorhinolaryngology-Head and Neck Surgery in 2009. Patient history and findings in physical and radiological examinations were registered. A questionnaire concerning patients' present pharyngeal symptoms was sent 3 and 6 years after their initial visit. Data from the Finnish Cancer Registry revealed whether patients developed malignancies within a 3-year follow-up. Based on medical records, neck ultrasound was performed for 37 (49 %) and videofluorography for 22 patients (29 %), with nonsignificant findings. After a 3- and 6-year follow-up, half patients indicated that they were asymptomatic or had fewer symptoms, whereas the rest had persistent symptoms. The Finnish Cancer Registry data confirmed that globus patients developed no head and neck malignancies during a 3-year follow-up. In the present study, neck ultrasound and videofluorography showed no additional benefit to evaluate the globus etiology in patients whose ENT status was normal. Half the globus patients suffered from persistent symptoms after a 3- and 6-year follow-up, indicating that globus may cause discomfort chronically. However, no patients developed malignancies during a 3-year follow-up.

Factors associated with hypertrophy of the lingual tonsils

OBJECTIVE

To identify factors that may be associated with lingual tonsil hypertrophy (LTH).

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary academic center.

SUBJECTS AND METHODS

Retrospective chart review identified 380 patients from August 2013 to April 2014 with graded lingual tonsils, documented during routine flexible laryngoscopy. Lingual tonsils were graded using a 0 to 4 scale: 0 = complete absence of lymphoid tissue, 1 = lymphoid tissue scattered over tongue base, 2 = lymphoid tissue covers entirety of tongue base with limited thickness, 3 = lymphoid tissue 5 to 10 mm in thickness, 4 = lymphoid tissue >1 cm in thickness (rising above the tip of epiglottis). Reflux symptom index (RSI collected during patient intake), presence of obstructive sleep apnea hypopnea syndrome (OSAHS; confirmed by polysomnogram), smoking habits, and basic demographics were gathered. Chi-square and linear multivariate regression analyses were used to identify significant relationships with LTH levels.

RESULTS

Overall, 59.8% were male with a mean age of 50.2 ± 16.5 years and BMI of 30.1 ± 18.0. Chi-square analysis revealed no significant relationship between OSAHS and LTH (P = .059). When RSI was stratified to ≥ 10 or < 10, a Cochran-Armitage test supported the trend hypothesis that as RSI increases, lingual tonsil grading increases. Significant univariate correlates included younger age (r = -0.307, P < .001) and smoking (r = 0.186, P = .002). Multivariate regression revealed the combination of younger age, increasing RSI, and smoking (r = -0.297, P < .001) to be a significant correlate.

CONCLUSION

LTH does not seem to be associated with OSAHS or BMI in this group of patients. High RSI, younger age, and gender may be factors associated with increased lingual tonsil thickness.

A Standardized Lingual Tonsil Grading System

Objective

Comparisons among studies involving the tongue base are limited by lack of a universal system for grading lingual tonsils. The authors propose a new standardized clinical grading system for lingual tonsil hypertrophy (LTH). Validation was assessed via an interexaminer agreement study.

Study Design

Kappa interrater agreement study.

Setting

Tertiary academic center.

Subjects and Methods

Video assessment: The proposed grading system consists of a 0-to-4 scale: 0 = complete absence of lymphoid tissue; 1 = lymphoid tissue scattered over tongue base; 2 = lymphoid tissue covering entirety of tongue base with limited vertical thickness; 3 = significantly raised lymphoid tissue covering entirety of the tongue base, approximately 5 to 10 mm in thickness; 4 = lymphoid tissue rising above the tip of the epiglottis, ≥1 cm in thickness. The vertical height of the tonsils is a clinical approximate. A teaching video demonstrated identification of this grading system. Fourteen trained otolaryngologists graded 20 video clips of the tongue base, recorded during flexible laryngoscopy. Live assessment: A second study was performed by 2 examiners directly examining the tongue base of 23 patients using flexible laryngoscopy.

Results

Video assessment: The overall Fleiss kappa statistic was 0.775 ( P < .0001). This denotes substantial agreement. Live assessment: The overall kappa for nominal data was 0.8665 ( P < .0001). This denotes near perfect agreement.

Conclusion

The substantial interexaminer correlation demonstrated during video assessment and perfect interexaminer correlation in live assessment indicate that the proposed grading system may be a valuable and useful tool in creating a common language to describe lingual tonsils.

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.

[Paresthesias of the upper respiratory tract]

This review concerns the modern views of etiology, diagnostics, and treatment of the patients presenting with paresthesias of the upper respiratory tract. Various concepts of etiology of this pathology are described along with the relevant diagnostic and therapeutic approaches. Special attention is given to the debatable aspects of diagnostics and treatment of the patients complaining of the feeling of a lump in the throat ("globus sensation"). The opinions of the domestic and foreign authors concerning this problem are considered. The necessity of the search for the new additional therapeutic procedures for the treatment of paresthesias of the upper respiratory tract, including the non-medicamental modalities, is substantiated. It is concluded that the development of the new adequate diagnostic and therapeutic algorithm is indispensable for the enhancement of the effectiveness of the management of the patients with paresthesias of the upper respiratory tract and complaints of "globus sensation".

Globus Pharyngeus: Effectiveness of Treatment with Proton Pump Inhibitors and Gabapentin

Objectives:

This study was performed to investigate the effectiveness of treatment of globus pharyngeus with proton pump inhibitors, gabapentin, or both.

Methods:

The subjects all presented with globus pharyngeus during the years 2006 to 2011. The inclusion criteria included a chief (primary) complaint of globus pharyngeus; a trial of proton pump inhibitor therapy for at least 2 months and/or a trial of gabapentin for at least 2 weeks; and at least 1 follow-up visit. We reviewed 331 charts; 87 patients met the criteria. The response to treatment was graded as none, partial, or complete.

Results:

Seventy-seven percent of all patients had improvement. Sixty-seven percent of patients had a partial or complete response from aggressive reflux management. Sixty-six percent of patients who had a trial of gabapentin reported improvement. Eight of 14 patients who did not improve with aggressive reflux management improved with gabapentin.

Conclusions:

A majority of patients with globus pharyngeus can be helped by treating reflux or neuralgia. A trial of gabapentin should be considered for patients who do not respond or only partially respond to reflux management.

Globus pharyngeus: a review of its etiology, diagnosis and treatment

Globus is a persistent or intermittent non-painful sensation of a lump or foreign body in the throat. It is a commonly encountered clinical condition that is usually long-lasting, difficult to treat, and has a tendency to recur. Furthermore, due to the uncertain etiology of globus, it remains difficult to establish standard investigation and treatment strategies for affected patients. As a first step for managing globus, careful history taking and nasolaryngoscopy are essential. Given the benign nature of the condition and the recent notion that gastroesophageal reflux disease is a major cause of globus, empirical therapy with a high dose of proton pump inhibitors is reasonable for patients with typical globus. If patients are nonresponsive to this therapy, definitive assessments such as endoscopy, multichannel intraluminal impedance/pH monitoring, and manometry should be considered. Speech and language therapy, anti-depressants, and cognitive-behavioral therapy can be helpful in patients whose symptoms persist despite negative investigations.

Do foreign bodies migrate through the body towards the heart?

Fixation of foreign bodies (FB), in the mucosa, can favor its migration, giving origin to the popular saying: “FB walk to the heart”.

Aim

describe the mechanisms involved in FB migration and how to diagnose them.

Methodology

From a sample of 3,000 foreign bodies, during 40 years, we analyzed four which had extra-lumen migration. We analyzed clinical, radiologic, endoscopic and ultrasound data collected at the medical documentation service.

Results

three clinical histories are presented, describing two fish bones and one piece of fish cartilage. FB shifting was analyzed in all of them. Migration started in the esophagus in two, one going to the aorta and the other to the neck area. In the other two, migration started in the pharynx, and the FB moved towards the prevertebral fascia and the other externalized in the submandibular region. The mechanisms and the risks posed to the patient, by FB migration, and the way to diagnose them are hereby discussed.

Conclusions

the study allows us to determine that FB can move through the body but not towards the heart. The study also serves as a warning sign: in cases of prolonged histories of FB ingestion, imaging studies are mandatory before endoscopic examination.

The diagnosis and management of globus: a perspective from Belgium

PURPOSE OF REVIEW

There is no standard protocol for managing globus pharyngeus. Checking the recent developments in this field regularly is of paramount importance.

RECENT FINDINGS

The commonest symptoms for which proton pump inhibitors are prescribed are globus (73%), followed by choking episodes (66%) and chronic cough (62%). Opinions remain divided about the role of upper esophageal sphincter hypertonicity in globus sensation. Upper aerodigestive tract malignancy is rare and must be excluded. Hypertrophy of the base of the tongue, heterotopic gastric mucosa, curled epiglottis, thyroid enlargement, rare benign or malignant tumors of the pharynx, excessive tension and Eagle's syndrome are possible causes. Flexible endoscopy is a frequently used examination, but there is a 'blind zone' under any upper aerodigestive tract malignancy, requiring rigid endoscopy for some indications. Barium swallow pharyngoesophagography should not be requested systematically for cancer detection. Dual-probe 24 h pH monitoring can help in the diagnosis of reflux. Impedance recording can be useful for the detection of acidic and nonacidic liquid and mist reflux events. Manometric measurements are consistent. Laryngopharyngeal symptoms, such as throat clearing, hoarseness, cough, and globus pharyngeus, are slower to resolve than esophageal symptoms. Nocturnal recovery of gastric acid secretion was demonstrated even with proton pump inhibitors. The symptoms disappeared with an additional H2 receptor antagonist.

SUMMARY

More awareness is required for patients complaining of globus pharyngeus.

ENT manifestations of gastroesophageal reflux

Gastroesophageal reflux (GER) has been associated with a variety of supraesophageal symptoms or diseases, including chronic cough, laryngeal disorders, rhinosinusitis, otitis media, and oral cavity lesions. In this article, we review the relationship between GER and ear, nose, and throat (ENT) symptoms. Data in the published literature are frequently conflicting. Only a few studies are controlled, and an evidence-based approach provides weak support for a causal association between GER and ENT manifestations. The GER diagnostic method should be standardized utilizing new parameters, and the definition and diagnostic accuracy of ENT pathologies also must be better specified. A firm connection remains controversial, and further randomized trials are needed.

Coblation-Assisted Lingual Tonsillectomy for Dysphagia Secondary to Tongue Base Hypertrophy

Objectives:

Lingual tonsillar hypertrophy is an underappreciated cause of dysphagia and is believed to impede swallowing function by inhibition of laryngeal elevation and epiglottic inversion due to mechanical interference by bulky tongue base tissue. We present a case of severe dysphagia secondary to idiopathic tongue base hypertrophy that was treated with coblation lingual tonsillectomy and tongue base reduction.

Methods:

We report a case and discuss the relevant literature regarding tongue base hypertrophy and surgical interventions to treat the enlarged base of the tongue.

Results:

Symptoms of dysphagia and globus sensation and signs of decreased epiglottic inversion and laryngeal penetration improved markedly after surgical reduction of hypertrophied lingual tonsillar tissue using coblation. Preoperative and postoperative clinical imaging and radiographs are presented to show the reduction of tongue base size, correlated with the patient's improved clinical function.

Conclusions:

Coblation-assisted lingual tonsillectomy and tongue base reduction can successfully treat dysphagia secondary to tongue base hypertrophy.

Proximal pharyngeal reflux correlates with increasing severity of lingual tonsil hypertrophy

Objective

To determine if degree of lingual tonsil hypertrophy(LTH) correlates with pharyngeal reflux.

Design

Prospective.

Methods

Patients with flexible laryngoscopic evidence of LTH were included. Degree of LTH was graded mild, moderate, or severe by two otolaryngologists blinded to pH study results. Threesensor pH study results were correlated to LTH grade.

Results

Nineteen patients were included (five with mild LTH, eight with moderate LTH, and six with severe LTH). Nasopharyngeal reflux (NPR) events <pH4 were found in four of six severe LTH patients but no mild or moderate LTH patients (P = 0.006). All severe LTH patients had NPR events <pH5, compared with only 4 of 11 mild or moderate LTH patients (P = 0.017). Atthe UES, 4 of 6 severe LTH patients had pathologic reflux, compared with 4 of 13 mild or moderate (P = 0.025). Interobserver reliability calculated by Cohen's kappa was excellent (0.92).

Conclusions

Our study shows a continuum of increasing pharyngeal reflux with higher LTH severity. Severe LTH may be a reliable physical sign of pharyngeal reflux, especially NPR. © 2008 American Academy of Otolaryngology-Head and Neck Surgery Foundation. All rights reserved.

Halitosis and gastroesophageal reflux disease: a possible association

OBJECTIVE

Previous reports have suggested that gastrointestinal (GI) diseases may cause halitosis. The aim of this study was to evaluate the relationship between upper GI conditions, especially gastroesophageal reflux disease (GERD), and halitosis.

PATIENTS AND METHODS

One hundred and thirty two consecutive patients complaining of upper GI symptoms were included in the study. All the patients completed a validated questionnaire that was designed to characterize and measure the severity of their symptoms. The questionnaire also contained questions about awareness and severity of oral bad breath. Following the filling of the questionnaire, the patients were physically examined and subjected to an upper GI endoscopy.

RESULTS

The final diagnosis among the 132 patients (M/F = 70/62, mean age 45.2 years, range 20-87 years) was GERD in 72 patients (55%), Functional dyspepsia in 52 (39%), Peptic ulcer in seven patients (5%) and gastric cancer in one patient (1%). Halitosis was significantly associated with the occurrence and severity of heartburn (P = 0.027), regurgitation (P = 0.002) sour taste (P < 0.001), belching (P = 0.001) and burburigmus (P = 0.006). Halitosis was not associated with upper abdominal pain, bloating, early satiety and chest pain. In relation to the final diagnosis, halitosis was significantly associated only with GERD (P = 0.002) but not with functional dyspepsia (P = 0.855) and peptic ulcer disease (0.765). No correlation was found between Helicobacter pylori infection status and halitosis occurrence and severity (analysis of variance F = 0.001, P = 0.977).

CONCLUSIONS

Halitosis is a frequent symptom of GERD and may be considered as an extra-esophageal manifestation of GERD. On the other hand, we did not find an association between functional dyspepsia, peptic ulcer disease and H. pylori infection with halitosis occurrence or severity.