Globus sensation and psychopathology in men: the Vietnam experience study

Globus sensation in obstructive sleep apnea patients; A cross-sectional study of 120 patients

PURPOSE

Globus pharyngeus (GP) is a common complaint in many disciplines, especially otolaryngology. Pharyngeal symptoms and abnormalities, including GP, are frequent in obstructive sleep apnea (OSA) patients. This study aims to investigate globus sensation in non-operated OSA patients.

METHODS

After translation and validation, the Laryngopharyngeal Measure of Perceived Sensation (LUMP) was administered to 120 untreated OSA patients. All patients underwent polysomnography and thorough physical examination. The association between LUMP scores and OSA measures was evaluated.

RESULTS

LUMP score had a significant correlation with the Epworth Sleepiness Scale (ESS) (Spearman's ρ = 0.269, p = 0.004), and BMI (Spearman's ρ = 0.249, p = 0.007), the anatomical position of the tongue (ρ = -0.191, p = 0.04) and the Friedman grade of tonsils (ρ = 0.241, p = 0.01). It correlated with SpO2 nadir, though it did not reach statistical significance.

CONCLUSION

The results of our study depict a relationship between a self-report measure of globus sensation and daytime sleepiness, BMI and tonsil size. In the absence of a direct relationship between OSA severity parameters and GP, we hypothesize a role for shared comorbidities and anatomical phenotypes. The increased frequency of GP in OSA patients should be considered when evaluating the complications of surgical interventions in these patients.

Practical multidisciplinary framework for the assessment and management of patients with unexplained chronic aerodigestive symptoms

OBJECTIVE

Patients experiencing unexplained chronic throat symptoms (UCTS) are frequently referred to gastroenterology and otolaryngology outpatient departments for investigation. Often despite extensive investigations, an identifiable structural abnormality to account for the symptoms is not found. The objective of this article is to provide a concise appraisal of the evidence-base for current approaches to the assessment and management of UCTS, their clinical outcomes, and related healthcare utilisation.

DESIGN

This multidisciplinary review critically examines the current understanding of aetiological theories and pathophysiological drivers in UCTS and summarises the evidence base underpinning various diagnostic and management approaches.

RESULTS

The evidence gathered from the review suggests that single-specialty approaches to UCTS inadequately capture the substantial heterogeneity and pervasive overlaps among clinical features and biopsychosocial factors and suggests a more unified approach is needed.

CONCLUSION

Drawing on contemporary insights from the gastrointestinal literature for disorders of gut-brain interaction, this article proposes a refreshed interdisciplinary approach characterised by a positive diagnosis framework and patient-centred therapeutic model. The overarching aim of this approach is to improve patient outcomes and foster collaborative research efforts.

Somatic anxiety in patients with laryngopharyngeal reflux

Objective

This study aimed to evaluate the relationship between laryngopharyngeal reflux (LPR) and anxiety in patients with LPR.

Design

Prospective, case-control study.

Setting

This study was conducted at a tertiary care center.

Participants

Sixty-four patients with LPR and 60 healthy controls.

Methods

Patients with LPR and healthy individuals (N = 64 and N = 60) were enrolled in this study. The Beck Anxiety Inventory (BAI) and reflux symptom index (RSI) were used to evaluate anxiety and reflux-related symptoms, respectively. The BAI can be classified into somatic and subjective symptom scales. The prevalence of anxiety was compared between patients with LPR and healthy individuals. This study evaluated the relationship between BAI and RSI scores.

Results

No statistical difference was found in the prevalence of anxiety between patients with LPR and healthy individuals (42.2% vs. 33.3%). However, the somatic anxiety symptom score was statistically higher in patients with LPR than in healthy individuals (p = .047). We observed a correlation between RSI and somatic anxiety scores of BAI in patients with LPR (rho = 0.286, p = .021).

Conclusion

Patients with LPR had more severe somatic anxiety symptoms, and somatic anxiety was associated with their LPR-related symptoms.

Determination of the Relationship between Globus-Type Complaints and COVID-19 Anxiety in Adult Cases with COVID-19

INTRODUCTION

Besides generalized symptoms, patients with COVID-19 also show otolaryngological (ENT) symptoms. Globus is one of these symptoms. Anxiety problems may accompany the disease, as well. This study investigated the relationship between globus symptoms and COVID-19 anxiety in patients diagnosed with COVID-19.

METHODS

The Turkish version of Glasgow-Edinburgh Throat Scale (GETS-T) and Coronavirus Anxiety Scale (CAS) was used to investigation of the relationship between globus symptoms and COVID-19 anxiety in patients diagnosed with COVID-19. They responded to the GETS-T for the evaluation of throat symptoms and determination of their severity. Additionally, it examined the level of dysfunctional anxiety associated with the coronavirus in COVID-19 patients by using the CAS. Data were collected through telephone interviews. There were 220 participants in a prospective cross-sectional study (110 COVID-19 patients and 110 non-COVID-19).

RESULTS

Results show the GETS-T total score to be significantly higher in the COVID-19 group than in the non-COVID-19 group (p < 0.001). As the GETS-T total score increased, CAS total score also increased significantly in the COVID-19 group. Total scores of GETS-T and CAS were found to be lower in the post-acute period than in the acute period in the COVID-19 group (p < 0.001).

CONCLUSION

This study confirms that globus-type symptoms may be present in the clinical appearance of COVID-19 infection. In addition, the results support the opinion held in the academic literature that there are positive correlations between globus sensation and psychosomatic etiology. Furthermore, the study concludes that the symptoms generalized as globus-type symptoms, which include sore throat, the feeling that something is stuck in the throat, and the inability to clear the throat, decrease and almost disappear after the first month of the disease.

Subjective Changes of Taste and Smell in Conjunction With Anxiety and Depression Are Associated With Symptoms in Globus Patients Without Evidence of Pathologic Acid Reflux

BACKGROUND/AIM

Patients suffering from globus often report decreased enjoyment when eating as well as a psychological abnormality. Some patients exhibit taste and smell changes (TSCs) when compared with the period before the diagnosis. The main aim of this study was to explore if TSCs and psychological abnormality are present in patients with globus, whether they are associated with the severity of throat symptoms, and the potential risk factors for globus.

PATIENTS AND METHODS

A total of 116 included patients who met the Rome IV diagnostic criteria for globus had been performed 24-hour pH monitoring, and the results shown no evidence of pathologic acid reflux. Meanwhile, 125 healthy controls were enrolled in this prospective study. All subjects completed several questionnaires including the Taste and Smell Survey, the Glasgow Edinburgh Throat Scale, the Hamilton Anxiety Scale (HAMA), and the Hamilton Depression Scale (HAMD). Multiple logistic regression was performed to explore the potential risk factors for globus. The study protocol was registered on the Chinese Clinical Trial Registry (No. ChiCTR-2100044972).

RESULTS

First, globus patients without evidence of pathologic acid reflux exhibited a 58.62% and 31.03% change in taste and smell, respectively, while their levels of anxiety and depression were 51.72% and 44.83%, respectively. Second, there was a significant difference in the taste score (Z=-4.954, P<0.001) and smell score (Z=-4.552, P<0.001) between globus group patients and healthy controls. Similarly, globus group patients had a higher HAMA score (9.52±2.437 vs. 3.12±1.059, t=6.867, P<0.001) and HAMD score (9.79±2.931 vs. 3.16±1.650, t=6.416, P<0.001) when compared with the healthy controls. Third, in globus group patients, the Glasgow Edinburgh Throat Scale was significantly correlated with the taste score (Spearman ρ=0.782; P<0.001), smell score (Spearman ρ=0.582; P=0.001), HAMA (Spearman ρ=0.676; P<0.001), and HAMD (Spearman ρ=0.672; P<0.001). In addition, the taste score was significantly correlated with HAMA (Spearman ρ=0.532; P=0.004) and HAMD (Spearman ρ=0.681; P<0.001), while the smell score was significantly correlated with HAMD (Spearman ρ=0.392; P=0.035). Finally, multivariate logistic regression revealed that TSCs, anxiety, and depression were significant independent risk factors for globus, with depression exhibiting the highest degree of association (odds ratio: 3.244).

CONCLUSIONS

TSCs and psychological comorbidities are prominent in globus patients without evidence of pathologic acid reflux. The obtained results indicated that there is a strong relationship between TSCs, psychological comorbidities, and globus. Therefore, awareness of this high prevalence of TSCs and psychological disorder may help to better understand the severity of throat symptoms.

Use of proton pump inhibitors to treat persistent throat symptoms: multicentre, double blind, randomised, placebo controlled trial

OBJECTIVE

To assess the use of proton pump inhibitors (PPIs) to treat persistent throat symptoms.

DESIGN

Pragmatic, double blind, placebo controlled, randomised trial.

SETTING

Eight ear, nose, and throat outpatient clinics, United Kingdom.

PARTICIPANTS

346 patients aged 18 years or older with persistent throat symptoms who were randomised according to recruiting centre and baseline severity of symptoms (mild or severe): 172 to lansoprazole and 174 to placebo.

INTERVENTION

Random blinded allocation (1:1) to either 30 mg lansoprazole twice daily or matched placebo twice daily for 16 weeks.

MAIN OUTCOME MEASURES

Primary outcome was symptomatic response at 16 weeks measured using the total reflux symptom index (RSI) score. Secondary outcomes included symptom response at 12 months, quality of life, and throat appearances.

RESULTS

Of 1427 patients initially screened for eligibility, 346 were recruited. The mean age of the study sample was 52.2 (SD 13.7) years, 196 (57%) were women, and 162 (47%) had severe symptoms at presentation; these characteristics were balanced across treatment arms. The primary analysis was performed on 220 patients who completed the primary outcome measure within a window of 14-20 weeks. Mean RSI scores were similar between treatment arms at baseline: lansoprazole 22.0 (95% confidence interval 20.4 to 23.6) and placebo 21.7 (20.5 to 23.0). Improvements (reduction in RSI score) were observed in both groups-score at 16 weeks: lansoprazole 17.4 (15.5 to19.4) and placebo 15.6 (13.8 to 17.3). No statistically significant difference was found between the treatment arms: estimated difference 1.9 points (95% confidence interval -0.3 to 4.2 points; P=0.096) adjusted for site and baseline symptom severity. Lansoprazole showed no benefits over placebo for any secondary outcome measure, including RSI scores at 12 months: lansoprazole 16.0 (13.6 to 18.4) and placebo 13.6 (11.7 to 15.5): estimated difference 2.4 points (-0.6 to 5.4 points).

CONCLUSIONS

No evidence was found of benefit from PPI treatment in patients with persistent throat symptoms. RSI scores were similar between the lansoprazole and placebo groups after 16 weeks of treatment and at the 12 month follow-up.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN38578686 and EudraCT 2013-004249-17.

Lansoprazole for persistent throat symptoms in secondary care: the TOPPITS RCT

BACKGROUND

Persistent throat symptoms are commonly attributed to 'laryngopharyngeal reflux'. Despite a limited evidence base, these symptoms are increasingly being treated in primary care with proton pump inhibitors.

OBJECTIVE

To assess the value of proton pump inhibitor therapy in patients with persistent throat symptoms.

DESIGN

This was a double-blind, placebo-controlled, randomised Phase III trial.

SETTING

This was a multicentre UK trial in eight UK ear, nose and throat departments.

PARTICIPANTS

A total of 346 participants aged ≥ 18 years with persistent throat symptoms and a Reflux Symptom Index score of ≥ 10, exclusive of the dyspepsia item, were recruited.

INTERVENTION

Random allocation (1 : 1 ratio) to either 30 mg of lansoprazole twice daily or matched placebo for 16 weeks.

MAIN OUTCOME MEASURE

Symptomatic response (i.e. total Reflux Symptom Index score after 16 weeks of therapy).

RESULTS

A total of 1427 patients were screened and 346 were randomised. The mean age was 52 years (standard deviation 13.7 years, range 20-84 years); 150 (43%) participants were male and 196 (57%) were female; 184 (53%) participants had a mild Reflux Symptom Index minus the heartburn/dyspepsia item and 162 (47%) had a severe Reflux Symptom Index minus the heartburn/dyspepsia item. A total of 172 patients were randomised to lansoprazole and 174 were randomised to placebo.

MAIN OUTCOMES

A total of 267 participants completed the primary end-point visit (lansoprazole, n = 127; placebo, n = 140), of whom 220 did so between 14 and 20 weeks post randomisation ('compliant' group); 102 received lansoprazole and 118 received placebo. The mean Reflux Symptom Index scores at baseline were similar [lansoprazole 22.0 (standard deviation 8.0), placebo 21.7 (standard deviation 7.1), overall 21.9 (standard deviation 7.5)]. The mean Reflux Symptom Index scores at 16 weeks reduced from baseline in both groups [overall 17.4 (standard deviation 9.9), lansoprazole 17.4 (standard deviation 9.9), placebo 15.6 (standard deviation 9.8)]. Lansoprazole participants had estimated Reflux Symptom Index scores at 16 weeks that were 1.9 points higher (worse) than those of placebo participants (95% confidence interval -0.3 to 4.2; padj = 0.096), adjusted for site and baseline severity.

SECONDARY OUTCOMES

Ninety-five (43%) participants achieved a Reflux Symptom Index score in the normal range (< 12) at 16 weeks: 42 (41%) in the lansoprazole group and 53 (45%) in the placebo group. A total of 226 participants completed the end-of-trial follow-up visit (lansoprazole, n = 109; placebo, n = 117), of whom 181 were 'compliant'. The mean Reflux Symptom Index scores at 12 months reduced from baseline in both groups [lansoprazole 16.0 (standard deviation 10.8), placebo 13.6 (standard deviation 9.6), overall 14.7 (standard deviation 10.2)]. A total of 87 (48%) participants achieved a Reflux Symptom Index score in the normal range at 12 months: 33 (40%) in the lansoprazole group and 54 (55%) in the placebo group. Likewise, the Comprehensive Reflux Symptom Score and Laryngopharyngeal Reflux - Health Related Quality of Life total scores and subscales all showed very similar changes in the lansoprazole and placebo cohorts at both 16 weeks and 12 months.

LIMITATIONS

Drop-out rate and compliance are issues in pragmatic clinical trials. The Trial Of Proton Pump Inhibitors in Throat Symptoms (TOPPITS) aimed to detect clinically relevant difference with 90% power. The 346 randomised participants reduced to 283 at the primary end point; 267 completed the primary outcome measure, 220 within the protocol time scale. Despite this, the powers to detect the clinically relevant difference in Reflux Symptom Index score at 16 weeks were 82% (compliant comparison) and 89% (pragmatic comparison). The lack of difference between lansoprazole and placebo is generalisable across NHS clinics.

CONCLUSIONS

Participants on lansoprazole did not report significantly better outcomes than participants on placebo on any of the three patient-reported outcome tools (Reflux Symptom Index, Comprehensive Reflux Symptom Score and Laryngopharyngeal Reflux - Health Related Quality of Life). This multicentre, pragmatic, powered, definitive Phase III trial found no evidence of benefit for patients by treating persistent throat symptoms with lansoprazole.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN38578686 and EudraCT number 2013-004249-17.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 3. See the NIHR Journals Library website for further project information.

Current Perception Threshold Testing in Pharyngeal Paresthesia Patients with Depression or Anxiety

PURPOSE

Satisfactory quantitative diagnostic approaches to pharyngeal paresthesia patients with depression or anxiety remain to be explored. This study investigated the plausibility of current perception threshold (CPT) testing in diagnosing pharyngeal paresthesia in patients with depression or anxiety.

PATIENTS AND METHODS

A total of 41 patients with pharyngeal paresthesia with depression or anxiety were recruited as the study group. Additionally, 60 healthy volunteers constituted the control group. The CPT values associated with 5-, 250-, and 2000-Hz electrical stimulation frequencies were measured at the palatal lingual arch and posterior third of the lingual body (two sensory nerve distribution sites in the pharynx). The normal range of CPT values of the above three frequencies was analyzed. The differences in the CPT values for sensory nerves were compared.

RESULTS

There were no significant differences in age and sex between the study and control groups. The CPT values of the pharynx at the two tested sites were not significantly correlated with age and gender. The CPT value of the study group was significantly lower than that of the control group in the palatal lingual arch and posterior third of the lingual body at an electrical stimulation of 5 Hz (p<0.05). No significant differences in the CPT values at other frequencies were found between the two groups.

CONCLUSION

CPT testing is effective in determining pharyngeal paresthesia in patients with depression and anxiety. Paresthesia of the pharyngeal sensory nerve region is caused by damaged C fibers.

Clinical and psychological characteristics of patients with globus

BACKGROUND/AIMS

Psychological factors are involved in many functional gastrointestinal disorders including globus. The aim of the present study was to assess the clinical and psychological correlates associated with globus.

PATIENTS AND METHODS

707 patients (69% female, 45.2 ± 16.5 years, BMI 27.2 ± 11.7 kg/m²) filled an MMPI-2 questionnaire and a standard Rome III clinical questionnaire and were included in this cross sectional study. Data analysis was performed using a univariate analysis and a multivariate logistic regression with a backwards selection procedure on significant scales after a univariate analysis.

RESULTS

140 patients (20%) reported suffering from globus. Globus appeared to be associated with older age (P = 0.001; OR = 1.022; 95% CI = [1.009-1.035]), increased BMI (P = 0.007; OR = 1.029; 95% CI = [1.008-1.051]), higher prevalence of regurgitations (P = 0.008; OR = 2.189; 95% CI = [1.228-3.902]), heartburn (P = 0.001 OR = 2.227; 95% CI = [1.406-3.530]), dysphagia (P < 0.001; OR = 2.399; 95% CI = [1.500-3.837]), epigastric pain (P < 0.001; OR = 3.768; 95% CI = [1.880-7.552]) and nonspecific dyspepsia (P = 0.018; OR = 1.786; 95% CI = [1.106-2.881]), and a higher score of hysteria (P = 0.008 OR = 1.034; 95% CI = [1.009-1.059]). By comparison with patients who reported globus and scores of hysteria in the normal range (n = 73), patients complaining of globus associated with high scores of hysteria (n = 67) have high scores of hypochondriasis (P < 0.001; OR = 1.235; 95% CI = [1.142-1.336]), high levels of Psychopathic deviate (P = 0.005; OR = 1.091; 95% CI = [1.026-1.161]) and a higher, but not significant, prevalence of complaints of regurgitation (P = 0.052; OR = 4.022; 95% CI = [0.989-16.351]).

CONCLUSION

Approximately 50% of the patients complaining of globus have a high score of hysteria associated with other personality disorders, and complain more frequently of regurgitation than other patients complaining of globus. These results tend to confirm that globus has a strong, although not systematic, connections with some specific personality disorders.

Prevalence of depression and anxiety among otolaryngology outpatients at Jordan University Hospital

PURPOSE

To determine the prevalence of depression and anxiety among otolaryngology outpatients at Jordan University Hospital.

METHODS

A cross-sectional observational study was conducted between January 2017 and February 2018. The sample included 1328 otolaryngology adult outpatients, who completed (PHQ-9) and (GAD-7) questionnaires for depression and anxiety. Sociodemographic and clinical data were recorded.

RESULTS

Depression and anxiety prevalence rates were 36.1% and 22.9%. The significant risk factors found for them were: age range 30 to 50 years, female sex, divorced status, smoking, alcohol drinking, asthma, family history of psychiatric illness, chronic illnesses, negative life events, secondary education, unemployment, low income, globus pharyngeus, tinnitus, and dizziness.

PRACTICE IMPLICATIONS

Healthcare providers should have the vigilance to suspect and treat these disorders to improve patients' symptoms and quality of life.

Anorexia, Oral Health and Antioxidant Salivary System: A Clinical Study on Adult Female Subjects

The aim of this study was to compare the oral health status and salivary antioxidant system between patients diagnosed with anorexia nervosa (AN) and healthy controls. A total of 25 female AN patients and 25 matched healthy controls were enrolled. Clinical parameters and saliva samples were collected for each patient. Two questionnaires to investigate oral health and hygiene were administered. Superoxide Dismutase (SOD) activity and High Reactive Oxygen Species (hROS) were evaluated. Salivary concentration of SOD was significantly higher in subjects with AN compared with control group (1.010 ± 0.462 vs. 0.579 ± 0.296 U/mL; p = 0.0003). No significant differences between groups were identified for hROS (233.72 ± 88.27 vs. 199.49 ± 74.72; p = 0.15). Data from questionnaires indicated that, although most of the patients recognized the oral hygiene importance in maintaining a good oral health, more than half of them had poor oral hygiene. Altered biochemical composition of saliva in patients with AN could be interpreted as an effective defence mechanism against oxidative stress. Moreover, despite the discrepancy between clinical findings and perception of the oral health in AN population arose, the quality of life of these patients appears not to be significantly affected by their dental condition.

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.

Association Between Patient Review of Systems Score and Somatization

Importance

Somatization is a condition in which psychological distress is manifested by medically unexplained symptoms, and it is prevalent in all medical specialties, including otolaryngology. Recognition of somatization can be difficult, and there are limited methods available.

Objectives

To determine whether patients with somatization respond differently to the review of systems (ROS) portion of the patient interview and whether the ROS can be used to identify patients with somatization.

Design, Setting, and Participants

A retrospective review of medical records of 2120 consecutive consultations of English- or Spanish-speaking patients aged 18 to 89 years who presented to the otolaryngology clinic from January 1, 2014, to November 10, 2015, was conducted to compare how the ROS of patients with chief complaints associated with somatization (group B: globus sensation, dizziness, and tinnitus) differs from those with symptoms more often associated with objective findings (group A: nasal obstruction, hoarseness, and hearing loss); a total of 605 patients were included. Objective clinical findings after physical examination and related testing were reviewed and classified as either significant, marginal, or absent. Current or past psychiatric comorbidities were also examined.

Main Outcomes and Measures

Number of affirmative responses on a standardized, 69-point ROS was recorded as a ROS score (ROSS). Objective clinical findings, symptoms, and psychiatric comorbidities were recorded.

Results

Of the 605 patients included in the analysis, 346 (57.2%) were women, and the mean (SD) age was 51.6 (15.7) years. Among patients with medically unexplained symptoms (median, 11; range, 0-39), the ROSS was higher compared with those with objective clinical findings (median, 6; range, 0-31) (median difference, 4; 95% CI, 3 to 6). Group A (hoarseness, nasal obstruction, and hearing loss: median ROSS, 6, range, 0-41) exhibited lower ROSS than group B (dizziness, globus sensation, and tinnitus: median ROSS, 9; range, 0-39) (median difference, -2; 95% CI -3 to -1). Psychiatric comorbidity (median, 10; range, 0-41) was associated with higher ROSS than patients without psychiatric comorbidity (median, 5.5; range, 0 to 36) (median difference, 5; 95% CI, 3 to 6).

Conclusions and Relevance

The manner in which patients respond to a standardized ROS differs in those with medically unexplained symptoms and in those with psychiatric disease. The ROS offers information beyond the actual systems review, and may be useful in the identification of somatization.

Dynamic swallowing study for globus patients

Objective

To examine whether pharyngeal swallowing function is impaired in globus patients with swallowing difficulty by dynamic swallowing study.

Methods

Dynamic swallowing studies were performed on 80 normal adult volunteers and 33 globus patients with swallowing difficulty. Objective parameters such as maximum displacement of the hyoid bone, pharyngeal transit time, pharyngeal constriction ratio, and maximum opening of the esophageal entrance were measured, which were closely associated with the pharyngeal swallowing function in the swallowing process.

Results

There were no significant differences between globus patients and normal adults in hyoid bone displacement, pharyngeal transit time, pharyngeal constriction ratio, or maximum opening of the esophageal entrance (p > 0.05).

Conclusion

The results of the dynamic swallowing study indicated that the pharyngeal swallowing function of globus patients was not impaired.

Esophageal Sensorimotor Function and Psychological Factors Each Contribute to Symptom Severity in Globus Patients

OBJECTIVES

Altered upper esophageal sphincter (UES) and esophageal body (EB) sensorimotor function and psychosocial factors may both be involved in symptom generation in globus, but their common impact is not yet assessed. The aim of the study is (1) to compare UES and EB sensitivity and compliance of globus patients with healthy controls (HC); (2) to study the association of globus symptom severity (GSS) with UES and EB sensitivity and compliance, UES motor function and psychosocial factors.

METHODS

In 58 globus patients, GSS, somatization, and anxiety disorders were determined using validated questionnaires. In 26 HC and 42/58 patients, UES and EB sensitivity and compliance were assessed twice using barostat measurements. UES function of 27 globus patients was evaluated using high-resolution manometry. Bivariate correlations and a general linear model tested the association of these factors with GSS.

RESULTS

UES and EB compliance did not differ between globus patients and HC. Upon repeated distension, UES habituation was seen in both groups, whereas EB sensitization (23.3±1.3 vs. 19.5±1.5 mm Hg, P<0.0001) only occurred in globus patients, (P=0.038). UES compliance (ρ=0.37, P=0.04), change in EB compliance upon repeated distension (ρ=0.45, P=0.007), somatization (ρ=0.43, P=0.003), panic disorder (t=3.04, P=0.004), and post-traumatic stress severity (ρ=0.40, P=0.005) were associated with GSS. UES compliance and somatization were independently associated with GSS. A trend (P=0.061) was found for the association of GSS with change in EB compliance.

CONCLUSIONS

UES compliance, change in EB compliance, and somatization explain 40% of the variance in GSS. This indicates that globus is a complex disorder of the brain-gut axis rather than a "psychosomatic" disorder or a peripheral esophageal disorder.

Age, Gender and Women's Health and the Patient

Patients with functional gastrointestinal disorders (FGIDs) often experience distress, reduced quality of life, a perceived lack of validation, and an unsatisfactory experience with health care providers. A health care provider can provide the patient with a framework in which to understand and legitimize their symptoms, remove self-doubt or blame, and identify factors that contribute to symptoms that the patient can influence or control. This framework is implemented with the consideration of important factors that impact FGIDs, such as gender, age, society, and the patient's perspective. Although the majority of FGIDs, including globus, rumination syndrome, IBS, bloating, constipation, functional abdominal pain, sphincter of Oddi dyskinesia, pelvic floor dysfunction, and extra-intestinal manifestations, are more prevalent in women than men, functional chest pain, dyspepsia, vomiting, and anorectal pain do not appear to vary by gender. Studies suggest sex differences in somatic but not visceral pain perception, motility, and central processing of visceral pain; although further research is required in autonomic nervous system dysfunction, genetics and immunologic/microbiome. Gender differences in response to psychological treatments, antidepressants, fiber, probiotics, and anticholinergics have not been adequately studied. However, a greater clinical response to 5-HT3 antagonists but not 5-HT4 agonists has been reported in women compared with men.

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.

The prospective association between childhood cognitive ability and somatic symptoms and syndromes in adulthood: the 1958 British birth cohort

BACKGROUND

Cognitive ability is negatively associated with functional somatic symptoms (FSS) in childhood. Lower childhood cognitive ability might also predict FSS and functional somatic syndromes in adulthood. However, it is unknown whether this association would be modified by subjective and objective measures of parental academic expectations.

METHODS

14 068 participants from the 1958 British birth cohort, whose cognitive ability was assessed at 11 years. Outcomes were somatic symptoms at 23, 33 and 42 years. Self-reported irritable bowel syndrome (IBS), chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) and operationally defined CFS-like illness were measured at 42 years.

RESULTS

Lower cognitive ability at age 11 years was associated with somatic symptoms at ages 23, 33 and 42 years. Adjusting for sex, childhood internalising problems, previous somatic symptoms and concurrent psychological symptoms, childhood cognitive ability remained negatively associated with somatic symptoms at age 23 years (β=-0.060, 95% CI -0.081 to -0.039, p<0.01), 33 years (β = -0.031, 95% CI -0.050 to -0.011, p<0.01), but not with somatic symptoms at 42 years. Overall, we found no clear association between lower childhood cognitive ability and CFS/ME, CFS-like illness and IBS. Associations between cognitive ability and somatic symptoms at 23 years were moderated by low parental social class, but not by subjective indicators of parental academic expectations.

CONCLUSIONS

Lower childhood cognitive ability predicted somatic symptoms, but not CFS/ME, CFS-like illness and IBS in adulthood. While earlier research indicated an important role for high parental academic expectations in the development of early-life FSS, these expectations do not seem relevant for somatic symptoms or functional somatic syndromes in later adulthood.

High-resolution Manometry and Globus: Comparison of Globus, Gastroesophageal Reflux Disease and Normal Controls Using High-resolution Manometry

Background/Aims

Globus is a foreign body sense in the throat without dysphagia, odynophagia, esophageal motility disorders, or gastroesophageal reflux. The etiology is unclear. Previous studies suggested that increased upper esophageal sphincter pressure, gastroesophageal reflux and hypertonicity of esophageal body were possible etiologies. This study was to quantify the upper esophageal sphincter (UES) pressure, contractile front velocity (CFV), proximal contractile integral (PCI), distal contractile integral (DCI) and transition zone (TZ) in patient with globus gastroesophageal reflux disease (GERD) without globus, and normal controls to suggest the correlation of specific high-resolution manometry (HRM) findings and globus.

Methods

Fifty-seven globus patients, 24 GERD patients and 7 normal controls were studied with HRM since 2009. We reviewed the reports, and selected 5 swallowing plots suitable for analysis in each report, analyzed each individual plot with ManoView. The 5 parameters from each plot in 57 globus patients were compared with that of 24 GERD patients and 7 normal controls.

Results

There was no significant difference in the UES pressure, CFV, PCI and DCI. TZ (using 30 mmHg isobaric contour) in globus showed significant difference compared with normal controls and GERD patients. The median values of TZ were 4.26 cm (interquartile range [IQR], 2.30-5.85) in globus patients, 5.91 cm (IQR, 3.97-7.62) in GERD patients and 2.26 cm (IQR, 1.22-2.92) in normal controls (P = 0.001).

Conclusions

HRM analysis suggested that UES pressure, CFV, PCI and DCI were not associated with globus. Instead increased length of TZ may be correlated with globus. Further study comparing HRM results in globus patients within larger population needs to confirm their correlation.

High-resolution Manometry and Globus: Comparison of Globus, Gastroesophageal Reflux Disease and Normal Controls Using High-resolution Manometry

BACKGROUND/AIMS

Globus is a foreign body sense in the throat without dysphagia, odynophagia, esophageal motility disorders, or gastroesophageal reflux. The etiology is unclear. Previous studies suggested that increased upper esophageal sphincter pressure, gastroesophageal reflux and hypertonicity of esophageal body were possible etiologies. This study was to quantify the upper esophageal sphincter (UES) pressure, contractile front velocity (CFV), proximal contractile integral (PCI), distal contractile integral (DCI) and transition zone (TZ) in patient with globus gastroesophageal reflux disease (GERD) without globus, and normal controls to suggest the correlation of specific high-resolution manometry (HRM) findings and globus.

METHODS

Fifty-seven globus patients, 24 GERD patients and 7 normal controls were studied with HRM since 2009. We reviewed the reports, and selected 5 swallowing plots suitable for analysis in each report, analyzed each individual plot with ManoView. The 5 parameters from each plot in 57 globus patients were compared with that of 24 GERD patients and 7 normal controls.

RESULTS

There was no significant difference in the UES pressure, CFV, PCI and DCI. TZ (using 30 mmHg isobaric contour) in globus showed significant difference compared with normal controls and GERD patients. The median values of TZ were 4.26 cm (interquartile range [IQR], 2.30-5.85) in globus patients, 5.91 cm (IQR, 3.97-7.62) in GERD patients and 2.26 cm (IQR, 1.22-2.92) in normal controls (P = 0.001).

CONCLUSIONS

HRM analysis suggested that UES pressure, CFV, PCI and DCI were not associated with globus. Instead increased length of TZ may be correlated with globus. Further study comparing HRM results in globus patients within larger population needs to confirm their correlation.

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.

Intelligence in childhood and chronic widespread pain in middle age: the National Child Development Survey

Psychological factors are thought to play a part in the aetiology of chronic widespread pain. We investigated the relationship between intelligence in childhood and risk of chronic widespread pain in adulthood in 6902 men and women from the National Child Development Survey (1958 British Birth Cohort). Participants took a test of general cognitive ability at age 11 years; and chronic widespread pain, defined according to the American College of Rheumatology criteria, was assessed at age 45 years. Risk ratios (RRs) and 95% confidence intervals (CIs) were estimated using log-binomial regression, adjusting for sex and potential confounding or mediating factors. Risk of chronic widespread pain, defined according to the American College of Rheumatology criteria, rose in a stepwise fashion as intelligence fell (P for linear trend <0.0001). In sex-adjusted analyses, for an SD lower intelligence quotient, the RR of chronic widespread pain was 1.26 (95% CI 1.17-1.35). In multivariate backwards stepwise regression, lower childhood intelligence remained as an independent predictor of chronic widespread pain (RR 1.10; 95% CI 1.01-1.19), along with social class, educational attainment, body mass index, smoking status, and psychological distress. Part of the effect of lower childhood intelligence on risk of chronic widespread pain in midlife was significantly mediated through greater body mass index and more disadvantaged socioeconomic position. Men and women with higher intelligence in childhood are less likely as adults to report chronic widespread pain.

Medically unexplained symptoms and somatisation in ENT

Background:

Somatisation has been described as the perception of a physiological event influenced by emotion.

Method:

A review of the medical literature was carried out using the following Medical Subject Headings: somatisation (which identified 357 articles), medically unexplained symptoms (749 articles), unexplained or idiopathic dizziness (142 articles), tinnitus (360 articles), catarrh (1068 articles) and globus pharyngeus (3114 articles).

Results:

Up to 40 per cent of out-patient attendances have medically unexplainable symptoms. In ENT clinics, this includes patients with dizziness, tinnitus, ‘pseudo’ eustachian tube dysfunction, being ‘unable to hear’, catarrh and postnasal drip, atypical facial pain, globus pharyngeus, and functional dysphonia. Medical explanations of these symptoms often differ from patients' perceptions. Demonstrating normal test results and providing reassurance have little effect on patients' doubts and anxieties. Consultations that recognise the symptoms and their impact, and offer a tangible and involving explanation are more likely to satisfy and empower patients.

Conclusion:

The treatment of medically unexplained symptoms has changed in recent years; there is now more emphasis on psychological factors due to an association with anxiety and depression.

Eating disorders and oral health: a matched case-control study

The aim was to compare the oral health status of patients with eating disorders (EDs), with sex- and age-matched controls, with a view to identify self-reported and clinical parameters that might alert the dental healthcare professional to the possibility of EDs. All patients who entered outpatient treatment in an ED clinic during a 12-month period were invited to participate. Of 65 ED patients who started psychiatric/medical treatment, 54 agreed to participate. Eating disorder patients and controls answered a questionnaire and underwent dental clinical examinations. Multivariate analysis identified significantly higher ORs for ED patients to present dental problems (OR = 4.1), burning tongue (OR = 14.2), dry/cracked lips (OR = 9.6), dental erosion (OR = 8.5), and less gingival bleeding (OR = 1.1) compared with healthy controls. Sensitivity and specificity for the correct classification of ED patients and controls using the five variables was 83% and 79%, respectively. The ED patients with vomiting/binge eating behaviors reported worse perceived oral health (OR = 6.0) and had more dental erosion (OR = 5.5) than those without such behavior. In ED patients with longer duration of the disease, dental erosion was significantly more common. In conclusion, oral health problems frequently affect ED patients, and this needs to be considered in patient assessment and treatment decisions.

Non-voice-related throat symptoms: comparative analysis of laryngopharyngeal reflux and globus pharyngeus scales

Background:

This study calculated the comparability of two throat symptom assessment scales devised to evaluate either laryngopharyngeal reflux or globus.

Setting:

United Kingdom hospital out-patient departments.

Method:

A total of 334 subjects, with and without throat symptoms, completed the Reflux Symptom Index and/or the Glasgow and Edinburgh Throat Scale. The following were calculated for the resultant data: Cronbach's α coefficient, principal component analysis, Kaiser normalisation, varimax and oblimin rotation, and eigenvalues.

Results:

Analysis of data from the Reflux Symptom Index and the Glasgow and Edinburgh Throat Scale revealed clearly similar symptom domains regarding (1) coughing and blockage, and (2) globus or postnasal drip or throat-clearing, as did combined analysis of their amalgamated items. Both instruments had good overall internal consistency (α = 0.75 and 0.81, respectively). The ‘heartburn or reflux’ item in the Reflux Symptom Index mapped poorly to each underlying factor.

Discussion:

The most commonly used laryngopharyngeal reflux and globus assessment questionnaires appear to detect very similar symptom clusters. The management of throat disorders may previously have been over-reliant on the presenting pattern of throat symptoms. Our findings indicate a need to revisit the traditional clinical classification of throat symptoms.