Globus pharyngeus: radiographic evaluation and 24-hour pH monitoring of the pharynx and esophagus in 22 patients

Poor consistency between reflux symptom index and laryngopharyngeal pH monitoring in laryngopharyngeal reflux diagnosis in Chinese population

Background

It is unknown whether the reflux symptom index (RSI) can replace pH monitoring as a diagnostic tool for laryngopharyngeal reflux (LPR) in Chinese people. The relationships between reflux parameters and LPR symptoms also require further research.

Methods

A total of 216 Chinese patients underwent laryngopharyngeal pH monitoring and filled out an RSI questionnaire. Laryngopharyngeal pH monitoring indicated a diagnosis of LPR for patients with 7 or more episodes of reflux or a reflex area index (RAI) of 6.3 or more. The RSI questionnaire indicated a diagnosis of LPR for patients with RSI scores of 14 or higher.

Results

Of the 216 patients, 85 were diagnosed with LPR as assessed by the RSI, and 72 were diagnosed with LPR through laryngopharyngeal pH monitoring. The Cohen's kappa coefficient comparing LPR diagnosis consistency between RSI score and laryngopharyngeal pH monitoring was 0.133 (P=0.007). This indicated the two diagnostic methods were consistent to a low degree; the total consistency rate was only 59.7% (129/216). The sensitivity of the RSI was 48.6% (35/72), and its specificity was 82.5% (94/114). For convenience, we named the nine symptom groups in the RSI sequentially as P1-P9. P1, P2, P3, P5, P6, and P7 were all correlated with at least one reflux parameter (P<0.05), but P4, P8, and P9 were not correlated with any reflux parameters (P>0.05). A total of 72 patients were diagnosed using pH monitoring, the gold standard for LPR diagnosis. The most common symptoms of LPR were found to be P9, P3, P8, P7, and P2 in these patients. The symptoms that most seriously affected patients were P9, P8, P3, P7, and P2.

Conclusions

The consistency in diagnosis of LPR between the RSI and laryngopharyngeal pH monitoring was poor, meaning the RSI is not a suitable LPR initial screening tool and cannot replace pH monitoring. Additionally, reflux symptoms P4, P8, and P9 were not correlated with any reflux parameters. The most prevalent LPR symptom was P9, followed by P3, P8, P7, and P2. The most severe symptom was also P9, followed by P8, P3, P7, and P2.

The effects of paroxetine and amitriptyline on the upper esophageal sphincter (UES) pressure and its natural history in globus pharyngeus

BACKGROUND

Antidepressant agents have been shown to be an effective and safe treatment method for patients with globus. However, there are few clinical trials dedicated to studying the effects of antidepressant agents on the natural history and upper oesophageal sphincter (UES) pressure of treated globus patients.

AIMS

To evaluate the effect of paroxetine and amitriptyline to prevent relapses in patients with globus, the simultaneous relationship between changes in UES pressure and improvement of globus symptoms were measured.

METHODS

Globus patients were randomised into amitriptyline, paroxetine and lansoprazole groups for a 6-week treatment period, and follow-up was extended to 12 additional months. Efficacy was evaluated in terms of the Glasgow-Edinburgh Throat Scale (GETS), and UES pressure was measured by standard oesophageal manometry.

RESULTS

Paroxetine therapy resulted in a higher withdrawal rate due to symptom relapse (15.9% vs 44.1%, P=0.01; 15.9% vs 64.7, P=0.001) than amitriptyline and lansoprazole. Furthermore, globus symptoms were alleviated with the decrease of UES pressure after paroxetine and amitriptyline treatment (r=0.620, P=0.02; r=0.575, P=0.03) CONCLUSIONS: This follow-up study indicates that paroxetine may alter the natural history of globus and can effectively be used for the long-term management of patients with the disease. Apart from the clinical benefits, paroxetine and amitriptyline can potentially decrease UES pressure.

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 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.

Role of salivary function in patients with globus pharyngeus

BACKGROUND

Our aim was to investigate the prevalence and the clinical role of salivary hypofunction in patients with globus sensation.

METHODS

We conducted a prospective observational study in 340 patients with globus pharyngeus. A standard questionnaire and (99m)Tc-pertechnate salivary scintigraphy were used to evaluate salivary hypofunction, with a full examination from the nasal cavity to the larynx (N = 303). We also investigated the effect of xerostomia management on globus symptoms (N = 252).

RESULTS

The symptom scores for xerostomia were higher in patients with severe globus (p < .05). Objective salivary hypofunction was noted in 57.4% of the patients, based on the reference values from control groups. Globus symptoms were more severe in the subgroup with salivary hypofunction (p = .0447). Conservative management of xerostomia significantly reduced the severity of globus at 1 and 3 months (p = .0002) regardless of salivary function.

CONCLUSIONS

Salivary hypofunction seems to be an aggravating factor in globus pharyngeus, but not a direct cause. Conservative management of xerostomia improves globus symptoms.

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.

Hyperdynamic upper esophageal sphincter pressure: a manometric observation in patients reporting globus sensation

OBJECTIVES

Although globus sensation is a common symptom, its pathogenesis is poorly defined. The aim of this study was to quantify the timing and magnitude of respiratory variation in upper esophageal sphincter (UES) pressure with high-resolution manometry (HRM) in patients with globus sensation, normal controls, and gastroesophageal reflux disease (GERD) patients without globus sensation.

METHODS

HRM recordings spanning from the hypopharynx to the stomach were analyzed in 131 consecutive globus patients with normal (64) and abnormal (67) distal esophageal motility. Resting UES pressure was analyzed up to 5 min before 10 5-ml water swallows. Change in UES pressure, its average magnitude between inspiration and expiration, and nadir UES relaxation pressure in globus patients were compared with those in 68 controls and 46 GERD patients without globus.

RESULTS

UES pressure typically increased during inspiration in both controls and patients. Respiration-related change in resting UES pressure was significantly amplified in globus patients (37.3 mm Hg) compared with controls (10.6 mm Hg) and GERD patients (13.0 mm Hg) (P<0.0001). A respiratory change in UES pressure>27 mm Hg was found in >60% of globus patients and <15% of controls and GERD patients without globus. This hyperdynamic UES was not associated with other abnormalities of esophageal motor function.

CONCLUSIONS

Hyperdynamic respiratory UES pressure changes were prevalent in patients reporting globus sensation irrespective of their deglutitive UES and distal esophageal motility. Although the etiology of this hyperdynamic UES is unclear, it does appear to be a frequent manometric observation in this patient group and may provide a new focus for further studies into pathogenesis and therapy.

Reflux and laryngitis: a systematic review

OBJECTIVES

To investigate and compare the prevalence of pharyngeal reflux (PR) events in normal controls and patients with clinically diagnosed reflux laryngitis.

METHOD

A systematic review of the literature was performed to identify all prospective studies on the results of 24-hour double-probe (pharyngeal and esophageal) pH monitoring in normal controls and in patients with symptoms and/or signs of reflux laryngitis.

RESULTS

Eleven relevant studies on 192 normal controls and 13 studies on 512 patients with reflux laryngitis were identified. One or more PR events were detected in 51 normal controls (22.9%; 95% CI, 13.9% to 33.3%) and in 154 of 422 patients (38.3%; 95% CI, 25.4% to 52.1%). There is no significant difference in the prevalence of PR events between normal controls and patients with reflux laryngitis (P = 0.079). In addition, the prevalence of PR events in patients with reflux laryngitis is much lower than reported in previous reviews on this subject.

CONCLUSION

This systematic review calculated that (1) only a minority of patients with clinically diagnosed reflux laryngitis will show PR events, and (2) there is no significant difference between the prevalence of PR events in patients with reflux laryngitis and healthy controls. At the moment, there is no reliable means to confirm reflux of gastric juice in patients with suspected reflux laryngitis. This diagnostic vacuum is fundamental and may pose important questions at the current concept of reflux of gastric juice as a common cause of laryngopharyngeal inflammation.

Utility of ambulatory pH monitoring and videofluoroscopy for the evaluation of patients with globus pharyngeus

Globus pharyngeous is not an uncommon disorder. The precise pathophysiology remains unclear. The aim of this study was to assess the clinical value of videofluoroscopy and ambulatory pH monitoring in patients with globus pharyngeus. Twenty-three patients (11M/12F, age range = 21-74 yr, mean = 50 yr) with globus pharyngeus entered the study. Radiographic examination of the pharynx and esophagus included videofluoroscopy and static radiography. A dual probe to measure the proximal and distal intraesophageal pH was inserted for 24 h. The results of dual-probe pH monitoring were normal in all patients. Videofluoroscopic results were abnormal in 8 patients, with 5 patients having laryngeal aspiration, 2 having stasis of barium in the vallecula and pyriform sinuses, and 4 having poor pharyngeal elevation. Cervical osteophytes were found in 13 patients with a frequent location at the C5-6 level. Ambulatory pH monitoring seemed to be less helpful for the evaluation of globus pharyngeus without reflux-like symptoms. Pharyngeal dysfunction is detected in a substantial proportion of patients by videofluoroscopy and radiography.

Reflux-induced laryngitis (laryngopharyngeal reflux)

Gastroesophageal reflux disease (GERD) has been increasingly associated with ear, nose, and throat (ENT) signs and symptoms. This condition, often referred to as laryngopharyngeal reflux (LPR) has become increasingly prevalent. However, the cause and effect relationship between GERD and laryngeal signs or symptoms is far from established. Many patients diagnosed initially with GERD as the cause of laryngeal signs do not symptomatically or laryngoscopically respond to aggressive acid suppression and do not have abnormal esophageal acid exposure by pH monitoring. This has resulted in frustration on the part of both gastroenterologists and ENT physicians and confusion on the part of patients. The current recommendations for the management of LPR patients call for initial empiric therapy with twice daily proton-pump inhibitors (PPIs) for 2 to 4 months. In those unresponsive to such therapy, diagnostic testing with prolonged pH monitoring may be indicated. However, in the majority of such patients, the reason for lack of response to PPI therapy may be irritation of the larynx by causes other than GERD. Surgical fundoplication in this group of patients has lower efficacy than in those with typical symptoms of GERD and is reserved for those with improvement on acid-suppressive therapy.

Therapy Insight: gastroesophageal reflux disease and laryngopharyngeal reflux

Gastroesophageal reflux disease has been increasingly associated with ear, nose and throat signs and symptoms; however, the cause and effect relationship between these two clinical entities is far from established. Many patients initially diagnosed with gastroesophageal reflux disease as the cause of laryngeal signs do not respond either symptomatically or laryngoscopically to aggressive acid suppression, and do not have abnormal esophageal acid exposure as measured by pH monitoring. This has resulted in frustration on the part of both gastroenterologists and ear, nose and throat physicians, and confusion on the part of patients. This review discusses the reasons for this controversy and highlights data that attempt to clarify this complex area.

A lump in the throat: Should speech and language therapists treat globus pharyngeus?

PURPOSE

The causes of the feeling of a lump in the throat (globus pharyngeus) are disputed. The symptoms are persistent and may lead clients to change their diet and suffer a reduced quality of life. Coexisting swallowing difficulties are often reported but no neurological or structural abnormality can be found. Psychological factors are likely to play a part in the condition and an eclectic approach to therapy appears to be warranted. This paper reports on a treatment programme that includes education, reassurance and the use of exercises.

METHOD

Fourteen clients participated. Their progress was assessed using the Glasgow and Edinburgh Throat Scale (GETS). A baseline period was used to assess the stability of their symptoms prior to therapy. This was followed by a group therapy session, use of the exercises and a further reassessment. Videofluoroscopy was conducted before and after therapy.

RESULTS

Clients score on the GETS improved. However, change was seen both during the baseline and the treatment making it unclear which aspects of the treatment were effective. Improvement during the baseline suggests that clients benefit from attention and reassurance. It is unclear, therefore, whether the therapy session and the exercises provide a specific benefit or a general benefit due to continued attention. The clients' videofluoroscopies were unchanged after therapy. The presence of residue after the swallow in the valleculae and the pyriform sinuses may contribute to the symptoms of globus.

CONCLUSION

The treatment is economical and appears to benefit clients. However, further research is needed to distinguish whether it has a specific effect or whether clients benefit from general attention and reassurance.

[Reflux esophagitis]

Gastroesophageal reflux disease (GERD) is one of the most prevalent diseases in the industrialized countries. Approximately 15-25% of adults suffer from reflux symptoms, characterized mainly by heartburn and/or regurgitation. Currently, antisecretory medication with proton pump inhibitors (PPI) or antireflux surgery are the established options for GERD-treatment. PPI are the therapeutic gold standard in acute, long-term or on-demand therapy of GERD. Since PPI do not restore the antireflux barrier but merely suppress acid secretion a life-long tablet adherence is required in most cases. In view of limitations of PPI and the potential risks of laparoscopic surgery, several endoscopic antireflux techniques were developed and may evolve as a valuable third option. However, so far objective long-term data are lacking for choosing the appropriate patient who will benefit most from endoluminal antireflux therapy.

The role of gastric and duodenal agents in laryngeal injury: an experimental canine model

BACKGROUND AND AIMS

The specific agents responsible for producing laryngeal signs and symptoms are currently unknown. We systematically evaluated the damaging role of gastric (acid and pepsin) and duodenal (bile acids and trypsin) ingredients individually and in combination on different laryngeal structures in an experimental canine model.

METHODS

A total of 42 beagles were studied (wt 9-15 kg each). After pentathol anesthesia all dogs underwent laryngoscopy. Injury (punch biopsy) was caused to the right vocal cord, medial arytenoid wall, and posterior cricoid wall on day 1. Pepsin (0.5 mg/ml), conjugated bile acid (CBA) (ursodeoxycholic acid, 300 micromolar), unconjugated bile acids (UBA) (cholic, 300 micromolar), trypsin (0.5 mg/ml) at pH 1-2, 4-5, and 6-7 were applied bilaterally to laryngeal sites three times per week for a total of 9-12 applications. Changes in laryngeal sites were scored visually. All dogs were sacrificed 1 day post last application. Laryngeal tissue was harvested and sent for blinded pathological examination. Histologic and visual scores were compared to each other and to control- and sham-treated dogs.

RESULTS

Pepsin alone (8.5 +/- 1.66) or combined with CBA (16.63 +/- 1.66) at pH 1-2 resulted in significant (p < 0.001) severe histological inflammation much greater than with other agents. Duodenal ingredients caused no or minimal degree of histological damage at all pH values. Visual scores above subtle erythema were significantly (p < 0.001) higher in the animals exposed to pepsin followed by CBA alone or in combination with pepsin at pH 1-2. There was a significant (p < 0.01) correlation between histology and visual scores (rho = 0.47; 95% CI = 0.30-0.60) for all sites combined. Of the three laryngeal sites, vocal cords were the most sensitive to injury by applied solutions.

CONCLUSIONS

(i) In acidic refluxate, pepsin and CBAs are the most injurious agents affecting laryngeal tissue. (ii) Duodenal agents do not play a significant role in causing laryngeal injury. (iii) Aggressive acid suppression should eliminate the injurious potential of any gastroduodenal refluxate.

Inheritance of cricopharyngeal dysfunction in Golden Retrievers

OBJECTIVE

To characterize a genetic component to cricopharyngeal dysfunction (CD) in Golden Retrievers.

ANIMALS

117 dogs.

PROCEDURE

The CD phenotype was determined by videofluoroscopy, and dogs were classified as affected if the upper esophageal sphincter (UES) did not open, if there were morphologic abnormalities of the UES, or if opening of the UES was delayed for > or = 6 videofluoroscopic frames (0.2 seconds) after closure of the epiglottis. All survey radiographic and videofluoroscopic studies were reviewed by the same radiologist.

RESULTS

Of the 117 dogs (47 males and 70 females) with a CD phenotype determined via videofluoroscopy, 21 dogs (18.0%) had abnormalities of the UES (affected). Of these 21 dogs, 9 were males (19.1% of all males) and 12 were females (17.1% of all females). The heritability of CD in a threshold model was estimated as 0.61, which established that CD could be passed from parent to offspring. Results of complex segregation analysis suggested that a single recessive allele of large effect contributed to the expression of this disease in Golden Retrievers.

CONCLUSIONS AND CLINICAL RELEVANCE

The determination that CD is inherited in Golden Retrievers is an important step in providing information for veterinarians attending dogs with this disorder. Breeders also require this information to make informed breeding decisions.

Laryngeal signs and symptoms and gastroesophageal reflux disease (GERD): a critical assessment of cause and effect association

Gastroesophageal reflux disease (GERD) has been associated increasingly with ear, nose, and throat (ENT) signs and symptoms. However, the cause and effect relationship between these two clinical entities are far from established. Many patients diagnosed initially with GERD as the cause of laryngeal signs do not symptomatically or laryngoscopically respond to aggressive acid suppression and do not have abnormal esophageal acid exposure by pH monitoring. This has resulted in frustration on the part of both gastroenterologists and ENT physicians and confusion on the part of patients. In this article we discuss the reasons for this controversy and highlight the recent data attempting to clarify this complex area.

Sensitivity and specificity of reflux-attributed laryngeal lesions: experimental and clinical evidence

In patients with signs and symptoms of laryngeal disorders, laryngoscopic examination and ambulatory pH monitoring often implicate gastroesophageal reflux disease (GERD). Experimental evidence highlights the importance of acidic reflux in laryngeal disorders. However, many patients with laryngeal signs that appear to be reflux related do not respond to aggressive acid suppression. This has resulted in controversy about the exact nature of the relation between GERD and ear, nose, and throat (ENT) signs and symptoms. Use of a combination of laryngoscopic examination and 24-hour ambulatory pH testing may improve the ability to identify those patients who would most benefit from acid suppression. Currently, however, these tests lack specificity, and the relationship remains unproved. This important task will require data from large-scale, randomized, controlled studies. Until we have determined these specific laryngeal signs from both a gastroenterology and an ENT perspective, we will be forced to use empiric therapy to identify those patients whose laryngeal signs and symptoms are due to GERD. Based on present data, we recommend aggressive acid suppression with twice-daily dosing of proton pump inhibitors for >or=4 months in these patients.

Cricopharyngeal spasm and Zenker's diverticulum

Cricopharyngeal spasm and Zenker's diverticulum represent disorders of the pharyngoesophageal junction for which a unifying theory of etiology has yet to be established. There is, however, a large body of evidence that supports an association with gastroesophageal reflux. Cricopharyngeal myotomy is the key to successful management of both disorders. Newer transoral endoscopic techniques of management have a lower overall morbidity than traditional open approaches in appropriately selected patients and are therefore gaining popularity as the preferred method of treatment.

Gastroesophageal reflux disease and the larynx

Gastroesophageal reflux disease (GERD) is associated with ear, nose, and throat (ENT) signs and symptoms. Previously, experiments in animal larynx suggested that acid in combination with pepsin resulted in more laryngeal injury than acid alone. Recently, similar experiments expanded on the above observation, finding no laryngeal inflammation with bile acid, trypsin, or combination of bile constituents in alkaline pH values. Combined, experimental evidence highlights the importance of acidic refluxates that contain pepsin and/or bile acids; however, many patients with laryngeal signs suggestive of GERD do not respond to aggressive acid suppression. This has resulted in controversy about the exact nature of relationship between GERD and ENT signs and symptoms. Because the diagnosis is initially suspected after a laryngoscopic examination by the ENT physicians, the suboptimal clinical response may be caused by the poor specificity of this exam in identifying GERD as the cause of patients' laryngeal symptoms. Hence, a multidisciplinary approach is often required in the optimum treatment of these patients.

Globo faríngeo y reflujo faringo-laríngeo

The globus sensation is one of the most frequent complaints in a basic ENT clinic. The etiology is still unknown, although some hypotheses have been suggested such as: psychological abnormalities, esophageal and cricopharyngeal muscle disfunction and the laryngopharyngeal reflux. Laryngopharyngeal reflux is the most frequent pathology related to the globus feeling. We've tried in this study to determine the incidence of laryngopharyngeal reflux in a group of 30 patients with globus feeling. We found 26.7% of these patients with an abnormal pH monitoring test.

Study on the function of pharynx & upper esophageal sphincter in globus hystericus

AIM: Globus pharyngeus is not an uncommon symptom. Presently, its unclear dated pathophysiology remains unclear and the disease can not be evaluated correctly with routine diagnostic methods. The objective of this study is to establish the normal values of pharyngeal and UES pressure, pharyngeal transit time in healthy volunteers and to compare the differences between healthy volunteers and patients with globus pharyngeus.

METHODS: Twenty-four healthy volunteers and thirty-two patients clinically diagnosed as globus pharyngeus entered the study. Pressures of pharynx and UES were measured. Pharyngeal transit time was measured by videofluoroscopic procedure.

RESULTS: Normal pressure of pharynx, and normal resting pressure of UES were 157.81 ± 63.86 mm Hg and 68.33 ± 37.56 mm Hg, respectively. The corresponding values in the patients were 175.50 ± 93.47 mm Hg and 71.38 ± 41.42 mm Hg. The pharyngeal transit time was 1.44 ± 0.30 s in normal control group, among them there were 4 cases with stasis of barium in the valleculae and one in the piriform sinus. No laryngeal penetration or aspiration was found. In the patient group, the pharyngeal transit time was 1.37 ± 0.41 s, among them there were 6 cases with stasis of barium in the valleculae and 5 in the piriform sinus. Nine cases had laryngeal penetration and 2 had aspiration. There were no statistical differences of pressures of pharynx, UES and the pharyngeal transit time between the two groups. But there was an association between laryngeal penetration and globus pharyngeus

CONCLUSION: Radiographic examination of the pharynx show specific findings of pharyngeal dysfunction in patients with globus pharyngeus. UES pressure is normal in most patients. Hence, we find no role for UES hypertonicity as an etiologic factor in globus pharyngeus.

Association of laryngopharyngeal symptoms with gastroesophageal reflux disease

OBJECTIVES

The prevalence of gastroesophageal reflux disease (GERD) in patients with laryngopharyngeal disorders is probably greater than realized.

STUDY DESIGN

Prospective study.

METHODS

To investigate the incidence of gastroenterological diseases including GERD in patients complaining of nonspecific laryngopharyngeal symptoms, laryngological examinations and gastroenterological evaluation with esophagogastroduodenoscopy were performed in 30 patients who refused to undergo 24-hour pH monitoring. Therapeutic intervention by behavioural and dietary modifications, antireflux medication, and eradication of Helicobacter pylori were assessed for changes in laryngeal findings and relief of symptoms.

RESULTS

Posterior laryngitis was present in 26 patients and in 19 of them was accompanied by erythema and edema of the interarytenoid region. Gastroenterological diseases such as GERD (43%), hiatal hernia (43%), and Helicobacter pylori-positive antrum gastritis (23%) were confirmed in 22 (73%) cases by esophagogastroduodenoscopy and histological examination of biopsy specimens. Medical antireflux treatment and eradication of Helicobacter pylori resulted in a remarkably therapeutic success rate of 90% because there was resolution of laryngopharyngeal symptoms and laryngeal findings in 20 of 22 patients with gastroenterological diseases for the mean follow-up period of 8 months.

CONCLUSIONS

Laryngopharyngeal symptoms can be predictors of gastroesophageal diseases and GERD because the most frequent underlying cause is supposed to be associated with posterior laryngitis. Medical antireflux treatment is effective for relief of symptoms and mucosal healing of posterior laryngitis.

The prevalence of Helicobacter pylori infection in benign laryngeal disorders

Helicobacter pylori (HP) is an accepted cause of chronic active gastritis and has a major causative role in peptic ulcers. It is a gastric carcinogen. Its role in nonulcer dyspepsia (NUD) is less clear, yet 50% of patients with NUD are infected with HP, and some recent literature demonstrates long-term improvement of symptoms following eradication. HP has been investigated in several other organ systems, but has not been investigated to any major degree in laryngeal disorders, a region that could be directly exposed to the bacterium from pharyngolaryngeal reflux. This study represents one arm of a larger study designed to investigate such a relationship. Of 101 patients with nonmalignant voice disorders presenting to our voice clinics, 54.5% tested positive for the H. pylori organism. Of the controls, 47.1% tested positive. When striated into age groups of < 45 years, 46-61 years, and > 62 years, and then age-matched with the controls, the likelihood of infection with the H. pylori organism was greater in both the experimental middle group, and in the middle group when combined with the elder group, than in the matched controls, and this difference demonstrated a trend approaching statistical significance. This finding is discussed in the light of other studies on HP and on gastroesophageal reflex (GER).

Globus pharyngeus: a postal questionnaire survey of UK ENT consultants

Globus pharyngeus is a common complaint often referred to the ENT outpatient department. The precise nature of globus pharyngeus and its aetiology remains something of a mystery. There is no uniform policy of management of this condition. A postal questionnaire was sent to all UK-based ENT consultants registered with the British Association of Otorhinolaryngolgists-Head and Neck Surgeons (BAO-HNS). The aim of this study was to ascertain if there was a favoured management policy by the majority of consultants. Our results indicate that there is a lack of consensus in the investigation and management of globus pharyngeus. Fourteen per cent do not perform any investigations, but would prescribe antacid medication if clinically indicated. The remainder would investigate in a variety of ways. The most common investigation is rigid endoscopy which is performed by 61% of respondents, followed by barium swallow (56%). The combination of endoscopy and barium swallow is routinely performed by 17.5% of respondents.

Value of pharyngography in patients without suprasternal symptoms

The purpose of the present paper was to determine if pharyngeal or cervical oesophageal lesions may present with distal symptoms. All patients presenting for barium swallow underwent examination of the pharynx and oesophagus. The pharyngeal examination included spot films of the pharynx as well as views of the pharyngo-oesophageal segment filmed at three frames per second. During the 18-month period of the present study interrogations were carried out to identify patients without symptoms in the cervical or suprasternal region. One hundred and twelve patients were identified; 58 were male and 54 were female. The age range was 18-84 years. Examinations revealed abnormalities within the pharynx in 42 patients (38%); of this group of 42, 34 also had an oesophageal abnormality. The majority of the pharyngeal findings were minor. There were, however, three patients who each had a pharyngeal abnormality (pharyngeal carcinoma, obstructive cricopharyngeal narrowing, pharyngo-oesophageal junction stricture) as well as an oesophageal lesion (hiatal hernia, achalasia, reflux oesophagitis), either of which may have been the source of the symptoms. The remaining eight patients (7%) of this group of 42 with detected pharyngeal abnormality had normal oesophageal examinations. Most of these were again minor changes and were unlikely to be significant. There was, however, one patient in whom the only abnormality was an infiltrative cancer of the posterior wall of the pharyngo-oesophageal junction. In conclusion, the identification of patients in the present study with pharyngeal lesions and without distal abnormal findings indicates that a proximal lesion may present with downstream symptoms. Furthermore, there were also patients in whom the examination found abnormalities in multiple segments of the pharynx and oesophagus. We suggest that examination of the pharynx is warranted as part of the barium swallow in patients without cervical or suprasternal symptoms.

Effect of Koso-san on globus pharyngeus

Twenty-three patients with globus pharyngeus were treated with Koso-san (TJ-70) at a dose of 7.5 g/day for at least 14 days. Symptoms disappeared in 18 cases and improved in 3 cases, therefore, the effective rate was 91.3% (21/23). The symptoms disappeared on average within 13.5 days. Terasawa qi-stasis scores were significantly decreased after the treatment. TJ-70 might thus be a remedy for globus pharyngeus with qi-stasis.

Pilot study of the oral omeprazole test for reflux laryngitis

BACKGROUND

Gastroesophageal reflux disease occasionally presents with laryngeal symptoms. Such patients are often referred for a gastroenterology evaluation. This study was designed to determine whether an empiric trial of high-dose omeprazole therapy could reliably identify patients with reflux laryngitis and thus obviate the need for a gastroenterology workup.

METHODS

Patients were evaluated with a history, physical examination, esophageal manometry, upper endoscopy, and 24-hour pH-metry for determination of the presence of absence of underlying gastroesophageal reflux disease and then received an empiric trial of oral omeprazole therapy (20 mg twice daily for 1 month). A positive omeprazole test result was defined as resolution of all laryngeal symptoms on completion of the empiric trial of therapy.

RESULTS

Two patients were classified as having no reflux, and eight were classified as having reflux. Omeprazole test results were positive in six patients. Five of six had reflux, but one patient had no evidence for reflux. Omeprazole test results were negative in four patients. Three of four had reflux, and one did not. Despite the absence of antisecretory therapy, laryngeal symptoms did not recur in either patient without reflux during follow-up. Laryngeal symptoms were managed in two of the three patients with reflux who had negative omeprazole test results and who were using inhalers in combination with histamine H2 receptor antagonist therapy for their reflux disease. One patient with reflux who had a negative omeprazole test result responded to higher doses of omeprazole, and the five patients with reflux who had positive omeprazole test results all responded to continuation of omeprazole.

CONCLUSIONS

The omeprazole test may be useful in confirming the suspicion of reflux laryngitis in patients suspected of having this disease after an otolaryngology evaluation. However, there is a potential for false-positive and false-negative test results. A gastroenterology evaluation may aid in the identification of false-positive test results by documenting the absence of reflux in certain responders.

Association of Esophageal Reflux and Globus Symptom: Comparison of Laryngoscopy and 24-Hour pH Manometry

Thirty-one patients with globus sensation were examined by dual probe pH manometry and videolaryngoscopy to investigate the role of gastroesophageal reflux disease in association with globus. Abnormal laryngeal findings, which included grossly abnormal and subtle changes, were seen in 17 patients. These findings included pharyngeal erythema (12 patients), interarytenoid pachydermia (11), laryngeal edema (11), arytenoid erythema (9), and thick mucus (3). Twenty-one of the 31 pH probe studies showed gastroesophageal reflux disease (14 grossly abnormal, 6 borderline abnormal) with Johnson and DeMeester composite scores for the distal probe. There was no correlation between the upright and supine position, nor was there correlation between positive laryngeal findings and a positive pH probe study. We conclude that globus sensation is often a nonspecific symptom of laryngopharyngeal irritation in which gastroesophageal reflux disease plays a significant role. Combining careful laryngoscopic examination with pH probe studies can help to differentiate between patients with organic pathology caused by gastroesophageal reflux disease and patients with other nonspecific laryngopharyngeal disorders.

A prospective controlled study of high-resolution thyroid ultrasound in patients with globus pharyngeus

The sensation of a lump in the throat may be the presenting symptom of thyroid enlargement, but the majority of thyroid abnormalities are undetectable by clinical examination. The thyroids of 43 patients with globus pharyngeus and 33 controls were prospectively examined by high-resolution ultrasound, to test the hypothesis that a higher incidence of impalpable thyroid abnormalities exists in patients with globus pharyngeus than in the normal population. Abnormalities were present in 31/43 (72%) patients with globus and in 11/33 (33%) controls (P < 0.001). Of the patients with globus, 17 had solitary nodules or cysts, 10 had multiple abnormalities and diffuse abnormality was present in four patients. Solitary nodules ranged from 4 to 29 mm. Impalpable, ultrasound-detectable abnormalities are significantly more common in patients with globus pharyngeus than in controls. Abnormalities of the thyroid gland may be responsible for globus symptoms.

Globus sensation: value of static radiography combined with videofluoroscopy of the pharynx and oesophagus

Pharyngo-oesophageal abnormalities are found in a high proportion of patients with globus sensation. This study compares the diagnostic value of static single- and double-contrast radiography of the pharynx and oesophagus with videofluoroscopy and with videofluoroscopy combined with static radiography in these patients. Pharyngeal and oesophageal morphology and motor function were studied in 130 consecutive patients with globus sensation (46 males, 84 females; mean age, 47 years) by means of static single and double-contrast radiography and by videofluoroscopy. Videofluoroscopy revealed significantly more functional and structural abnormalities compared to static radiography. Pharyngeal and/or oesophageal disorders were found in 89 vs. 47 patients (chi2 [1] = 19.82, P = 0.0001), pharyngeal abnormalities in 54 vs. 27 patients (chi2 [1] = 13.5, P < 0.0002), and oesophageal abnormalities in 72 vs. 27 patients (chi2 [1] = 28.13, P < 0.0001). Videofluoroscopy combined with static radiography revealed significantly more abnormalities than videofluoroscopy alone (chi2 [1] = 4.23, P < 0.05), and assessed mucosal details more reliably than videofluoroscopy alone. The most frequent abnormalities found were nonspecific oesophageal motor disorders, pharyngo-oesophageal sphincter dysfunction, pharyngeal stasis, achalasia, and laryngeal penetration or aspiration of barium. In most patients with globus sensation, pharyngeal and/or oesophageal abnormalities can be detected radiographically. Videofluoroscopy revealed significantly more functional but not morphological abnormalities than did static radiography. Videofluoroscopic studies combined with static radiography had a higher diagnostic value than videofluoroscopic studies alone.

Dynamic characteristic of gastro-oesophageal reflux in ambulatory patients with gastro-oesophageal reflux disease and normal control subjects

BACKGROUND

The aim of the study was to investigate the dynamic characteristics of pathologic gastro-oesophageal reflux.

METHODS

Five-channel ambulatory 24-h oesophageal pH monitoring was performed in 19 gastro-oesophageal reflux disease patients (age, 21-74 years) and in 19 healthy volunteers (age, 21-64 years). The pH was recorded at 3, 6, 9, 12, and 15 cm from the lower oesophageal sphincter (LOS), using a sample frequency of 4 Hz for each channel. Automated analysis included calculation of the ascending velocity of the refluxate and duration and extent (cm above the LOS) of all individual reflux episodes.

RESULTS

In the patients more upright reflux episodes reached the proximal sensor than in the controls (20% and 11%, respectively, P < 0.01). The duration of the reflux episodes (measured at 3 cm above the LOS) was longer in the patients than in controls (P < 0.0001). This effect was independent of the proximal extent of the reflux episodes. Ascending velocities of upright acid reflux were higher in controls (1.8 to 2.7 cm/sec) than in patients (0.7 to 2.2 cm/sec; P = 0.01).

CONCLUSIONS

The dynamic characteristics of pathologic reflux differ significantly from those of physiologic reflux.