The diagnosis and management of globus pharyngeus: our perspective from the United Kingdom

Management of functional communication, swallowing, cough and related disorders: consensus recommendations for speech and language therapy

Communication problems (eg, dysphonia, dysfluency and language and articulation disorders), swallowing disorders (dysphagia and globus), cough and upper airway symptoms, resulting from functional neurological disorder (FND), are commonly encountered by speech and language professionals. However, there are few descriptions in the literature of the most effective practical management approaches. This consensus document aims to provide recommendations for assessment and intervention that are relevant to both adults and young people. An international panel of speech and language professionals with expertise in FND were approached to take part. Participants responded individually by email to a set of key questions regarding best practice for assessment and interventions. Next, a video conference was held in which participants discussed and debated the answers to these key questions, aiming to achieve consensus on each issue. Drafts of the collated consensus recommendations were circulated until consensus was achieved. FND should be diagnosed on the basis of positive clinical features. Speech and language therapy for FND should address illness beliefs, self-directed attention and abnormal movement patterns through a process of education, symptomatic treatment and cognitive behavioural therapy within a supportive therapeutic environment. We provide specific examples of these strategies for different symptoms. Speech and language professionals have a key role in the management of people with communication and related symptoms of FND. It is intended that these expert recommendations serve as both a practical toolkit and a starting point for further research into evidence-based treatments.

Laryngopharyngeal Reflux: A State-of-the-Art Algorithm Management for Primary Care Physicians

Laryngopharyngeal reflux (LPR) is a common disease in the general population with acute or chronic symptoms. LPR is often misdiagnosed in primary care because of the lack of typical gastroesophageal reflux disease (GERD) symptoms and findings on endoscopy. Depending on the physician's specialty and experience, LPR may be over- or under-diagnosed. Management of LPR is potentially entirely feasible in primary care as long as General Practitioners (GPs) are aware of certain "red flags" that will prompt referral to a Gastroenterologist or an Otolaryngologist. The use of patient-reported outcome questionnaires and the consideration of some easy ways to diagnose LPR without special instrumentation oropharyngeal findings may help the GP to diagnose and often manage LPR. In this review, we provide a practical algorithm for LPR management for GPs and other specialists that cannot perform fiberoptic examination. In this algorithm, physicians have to exclude some confounding conditions such as allergy or other causes of pharyngolaryngitis and "red flags". They may prescribe an empirical treatment based on diet and behavioral changes with or without medication, depending on the symptom severity. Proton pump inhibitors and alginates remain a popular choice in order to protect the upper aerodigestive tract mucosa from acid, weakly acid and alkaline pharyngeal reflux events.

Upper esophageal sphincter dysfunction: diverticula-globus pharyngeus

The following discussion of upper esophageal sphincter dysfunction includes commentaries on the role of the cricopharyngeus muscle in reflux disease; the etiology and treatment of Zenker diverticulum; the use of videofluoroscopy in patients with dysphagia, suspicion of aspiration, or globus; the role of pH-impedance monitoring in globus evaluation; and treatment for reflux-associated globus.

Yield of neck CT and barium esophagram in patients with globus sensation

BACKGROUND AND PURPOSE

Globus sensation is common and difficult to treat. The purpose of our study was to compare the diagnostic and therapeutic efficacy of barium esophagram and neck CT in patients with isolated globus sensation, to determine which of these modalities should be preferred in the evaluation of this condition.

MATERIALS AND METHODS

We retrospectively identified patients presenting with isolated globus sensation from January 1, 2005, to December 31, 2012, who underwent neck CT or barium esophagram. We calculated the proportion of patients with abnormal findings, tabulated the nature of the abnormality, and reviewed the medical records to determine whether imaging changed management.

RESULTS

One hundred forty-eight neck CTs and 104 barium esophagrams were included. Five (3.4%) patients with neck CTs and 4 (3.9%) with barium esophagrams demonstrated significant findings related to the history of globus sensation. Of these, 1 (0.7%) neck CT and 1 (1.0%) barium esophagram resulted in a change in clinical management.

CONCLUSIONS

Imaging evaluation of the patient with uncomplicated globus sensation is unlikely to identify clinically significant imaging findings and is very unlikely to result in a change in clinical management, with a combined therapeutic efficacy of 0.8%. Thus, the routine use of imaging in the evaluation of patients with globus sensation cannot be recommended.

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.

Role of flexible transnasal esophagoscopy and patient education in the management of globus pharyngeus

BACKGROUND/PURPOSE

Globus pharyngeus and dysphagia are common complaints of patients referred to ear, nose, and throat (ENT) clinics. We aimed to establish an efficient method to rule out the presence of malignancy in patients with globus pharyngeus and dysphagia.

METHODS

The use of flexible transnasal esophagoscopy (TNE) was evaluated in 30 patients with globus pharyngeus and 6 patients with dysphagia. The patients were immediately informed of the findings on TNE examination, and then treatments were planned. All patients were treated with lansoprazole for 2 weeks and provided education on lifestyle changes at the initial examination and at the 3-month follow-up.

RESULTS

The patients reported an improvement in symptoms of globus pharyngeus after treatment (p<0.001). Follow-up TNE confirmed improvement with less dysphagia, erythema, and vocal cord edema evident (all p<0.001).

CONCLUSION

The use of TNE and patient education are efficient management strategies for patients with symptoms of globus pharyngeus and dysphagia.

The role of barium swallow pharyngoesophagography in the management of the globus pharyngeus: our ten years local experience of asian population

Patients with globus pharyngeus referred for barium swallow pharyngoesophagography in a local hospital from 1/7/1999 to 30/6/2009 were identified. Their fluoroscopic images were reviewed, and their outcomes were used as gold standard. A total of 908 patients with globus pharyngeus were referred for barium swallow in the period. There were 783 patients with normal barium swallow and 125 patients with abnormal barium swallow findings. All patients aged below 30 years had normal barium swallow result and unremarkable follow up. The sensitivity and specificity of barium swallow were 25.6 and 97.5% respectively; and the positive predictive value and negative predictive value were 61.5 and 89.1% respectively. The overall accuracy was 87.6%. Barium swallow is of limited diagnostic value in patients with typical globus pharyngeus, and it is not recommended in these patients, especially with young age.

Globus pharyngeus and extraesophageal reflux: simultaneous pH <4.0 and pH <5.0 analysis

OBJECTIVES/HYPOTHESIS

Weakly acid refluxes seem to play an important role in the pathogenesis of extraesophageal reflux. The aim of this study was to evaluate how proportional representation of patients with extraesophageal reflux in a group of patients with globus pharyngeus changes when we use both pH <4.0 as well as pH <5.0 as a pathological threshold for an extraesophageal reflux episode.

STUDY DESIGN

Prospective pH monitoring study of 46 patients.

METHODS

Patients with pure globus pharyngeus lasting more than 3 months were included in the study. The pH monitoring was performed (Smit technique) with double probes (fixed distance of 15 cm). The recorded data using only pH <4.0 and using both pH <4.0 along with pH <5.0 as thresholds for extraesophageal reflux episode were analyzed simultaneously. The reflux area index 4 >6.3 and reflux area index 5 >72.6 were considered as clear pathological extraesophageal reflux.

RESULTS

Extraesophageal reflux was proven in 23.9% patients with pure globus pharyngeus when standard analysis using only pH <4.0 was used as pathological threshold. If both pH <4.0 and pH <5.0 were used as the pathological threshold, clear extraesophageal reflux was found in four more (8.7%) patients.

CONCLUSIONS

This study indicates the possible role of weakly acid extraesophageal reflux episodes in some patients with globus pharyngeus. Other studies on this issue, including the use of biological markers such as signs of inflammation, are warranted.

Globus sensation and psychopathology in men: the Vietnam experience study

OBJECTIVE

To assess whether globus is associated with psychopathology in men. Globus-a persistent sensation of having a lump in the throat with no detectable physical cause-has long been thought a predominantly female disorder. Several small studies, based wholly or largely on women, suggested that globus is associated with higher levels of depression, anxiety, and somatic concern.

METHODS

Participants were 4240 male U.S. veterans who underwent detailed medical and psychological examinations in middle age. Psychological health was assessed by structured diagnostic interview and the clinical scales of the Minnesota Multiphasic Personality Inventory (MMPI). The MMPI includes an item on the presence of globus.

RESULTS

The prevalence of globus was 6.4%. Men with globus had an increased risk of being diagnosed with somatization disorder, odds ratio (OR) = 5.92, 95% Confidence Interval (CI) = 3.22, 10.9l; major depression, OR = 4.98, 95% CI = 3.63, 6.67; generalized anxiety disorder, OR = 3.70, 95% CI = 2.75, 4.90; posttraumatic stress disorder, OR = 3.50, 95% CI = 2.54, 4.76; and drug abuse or dependence, OR = 1.89, 95% CI = 1.15, 3.13; and they scored significantly higher on nine of the ten MMPI clinical scales. Globus was also associated with lower cognitive ability, socioeconomic and educational disadvantage, a higher pulse rate, and increased likelihood of being on antihypertensive medication.

CONCLUSIONS

Globus is linked with a wide range of psychopathology in men, notably depression and somatization disorder. Men presenting with globus might have developed that particular symptom to "represent" other, related and treatable psychopathology, which should also be investigated.