Superior thyroid cornu anatomical variation causing globus pharyngeous and Dysphagia

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.

Laryngeal anatomical variants and their impact on the diagnosis of mechanical asphyxias by neck pressure

The aims of this investigation were to determine the characteristics and prevalence of anatomical variants of the larynx apparatus and to evaluate the impact of these variants on the accurate diagnosis of laryngeal fractures. A population-based study was carried out, analyzing a series of 207 consecutive autopsied cases in the Institute of Legal Medicine of Galicia (Northwestern Spain). The prevalence of triticeal cartilage was 52.7% and that of agenesis of thyroid horns 10%. Calcification of the stylo-hyoid ligament accounted for 1.4%. We identified three new anatomical variants: the terminal segmentation of the thyroid horns (11.6%), ectopic superior thyroid horns (8%) and lateral thyrohyoid ossification (5.3%). These three names, based on anatomical criteria, are the author's proposal to solve the lack of uniformity in the designation of these variants. Agenesis of thyroid horns were related to the presence of ectopic superior thyroid horns in 93% of cases, either uni or bilateral. The combination of variants was present in 6.8% of the cases, being the terminal segmentation of the thyroid horns in association with triticeal cartilage the most frequent (3.8%). The probability of misdiagnosis due to the presence of anatomical variations in deaths by pressure on the neck was high in this population (71.5%). The prevalence of triticeal cartilage in more than half of the sample, determined an important rate of potential errors (46.4%), followed by the mistaken diagnoses induced by terminal segmentation of thyroid horns (7.3%) and by ectopic superior thyroid horns (6.3%). The likelihood of a misdiagnosed laryngeal fracture was greater if the thyroid cartilage was affected, with a higher proportion of false positives comparing to the hyoid bone (p<0.001). The higher frequency of thyroid fractures in neck pressure together with the prevalence and location of triticeal cartilage on the lower third of the lateral thyrohyoid ligament are the main reasons for these results. Further studies should be done with larger samples to expand epidemiological data and consolidate these results and their influence on the diagnosis of mechanical asphyxias.

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.

Laryngeal anomalies: Pitfalls in adult forensic autopsies

OBJECTIVE

This is the first paper to group together most of adult laryngeal anomalies or malformations which may be misinterpreted by the forensic pathologist and taken for a proof of violence.

MATERIAL AND METHODS

A review of the literature, to list the main pitfalls, to explain their nature and their origins.

RESULTS

We found two main categories, the congenital defects and the acquired anomalies.

CONCLUSIONS

The laryngeal region is complex. The pathologist must keep in mind anatomical variations or malformations, but also sequelae of old injuries and iatrogenic lesions. The survey, the patient's clinical history, the findings of the whole autopsy and, if necessary, histology may help to interpret a laryngeal anomaly.