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.

Office-based transnasal esophagoscopy biopsies for histological diagnosis of head and neck patients

OBJECTIVES/HYPOTHESIS

To present yield of transnasal esophagoscopy (TNE) biopsies of upper aerodigestive tract (UADT) lesions and define the role of TNE as a safe alternative to rigid endoscopy.

STUDY DESIGN

Retrospective case series.

METHODS

All patients who underwent TNE-guided biopsies attempted over a 2-year period were included. Patients were identified using coding records and outpatient diaries. Demographic data were recorded as well as the histological diagnosis and additional histological diagnostic procedures.

RESULTS

During the observation period, 134 TNE-guided procedures were attempted. The procedure could not be completed in 19 patients. There were 102/115 (89%) patients who did not require further interventions for histological diagnosis of the tumor. The most common biopsied area was the larynx (53), followed by the tongue base (29). The most common malignancy was invasive squamous cell carcinoma in 42/115 (36.5%).

CONCLUSIONS

The work presented in this article strongly suggests that TNE-guided biopsy is a valuable diagnostic tool for patients suspected of having carcinoma of the UADT.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:2721-2726, 2019.

Oesophageal causes of dysphagia localised only to the pharynx: Implications for the suspected head and neck cancer pathway

OBJECTIVES

Dysphagia is a presenting symptom of both pharyngeal and oesophageal cancers. The referral pathway choice is determined by whether it is thought to be oropharyngeal or oesophageal, and this is in turn influenced by whether dysphagia is perceived to be above or below the suprasternal notch. We studied the concordance between the presence of pharynx-localised dysphagia (PLD) and the location of the underlying disease processes.

DESIGN

A subset analysis of the Dysphagia Hotline Cohort, collected between 2004 and 2015, of patients with PLD and a structural diagnosis.

MAIN OUTCOME MEASURES

Information about patient demography and presenting symptoms were recorded. The incisor-to-pathology distance, and the nature of the pathology, were recorded. Logistic regression analysis was used to identify independent predictors of malignancy.

RESULTS

The study included 177 patients. There were 92 males, and mean age at presentation was 74 years. The commonest benign pathologies were cricopharyngeal dysfunction with or without pharyngeal pouch (n = 67), peptic stricture (n = 44) and Schatzki's ring (n = 11). There were 49 cases of cancer, including one hypopharyngeal cancer, one cervical oesophageal cancer, 28 cancers of the upper/mid-thoracic oesophagus, 15 cancers of the lower thoracic oesophagus and 4 cardio-oesophageal cancers. In 105 (59%) patients, PLD was caused by oesophageal disease. Independent predictors of malignancy were weight-change (loss >2.7 kg), a short history (<12 weeks) and presence of odynophagia. Nineteen (39%) of oesophageal cancers that presented with dysphagia that was localised only to the pharynx would have been beyond the reach of rigid oesophagoscopy.

CONCLUSIONS

Pharynx-localised dysphagia is more likely to be a referred symptom of structural oesophageal disease, including cancer, than a primary symptom of structural pharyngeal disease. Absence of additional alarm symptoms such as a short history, weight-loss, and odynophagia, do not adequately exclude the possibility of oesophageal cancer. When the differential diagnosis of PLD includes malignancy, cancer should be presumed to be arising from the oesophagus or the cardio-oesophageal region until proven otherwise. This requires direct visualisation of the mucosal surfaces of the oesophagus and the cardio-oesophageal region, using either transoral or transnasal flexible endoscopy, irrespective of whether the initial assessment occurs within head and neck or upper gastrointestinal suspected cancer pathways.