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AnttiMäkitie
EeroSihvo
SariAtula

Dysphagia and Globus Sensation (Globus Pharyngeus)

Essentials

  • Dysphagia should be identified and the patient referred for further investigations without delay. Dysphagia should be differentiated from the feeling of a lump in the pharyngeal region (globus sensation).
  • Globus sensation is a very common symptom, but when it is suspected the possibility of an organic disorder must be excluded first.
  • Dysphagia is an uncommon and serious symptom in comparison with other upper abdominal symptoms.
  • Dysphagia may also be a manifestation of a neurological condition, which usually would also have other symptoms.

Definition

  • In dysphagia, food does not travel forward from the mouth or pharynx, or becomes stuck in the oesophagus after swallowing (oral, pharyngeal and oesophageal phases of swallowing).
  • Globus sensation manifests as an intermittent or permanent feeling of a lump, pressure or discomfort in the middle of the throat, at the upper opening of the oesophagus. There is usually no pain, difficulty with swallowing or loss of weight.

Background

  • Patients usually seek medical help only after the symptoms have lasted for some weeks or months, even years. Rapid worsening of symptoms or troublesome dysphagia prompt an earlier consultation.
  • Globus sensation is more common in young people and in women. It may be associated with psychological stress and changes in circumstances, and the symptoms are often combined with fear of cancer.
  • Dysphagia is rarely the only symptom in neurological conditions, and it often develops only after the condition is more advanced. The motor neurone disease amyotrophic lateral sclerosis (ALS Amyotrophic Lateral Sclerosis (ALS)) is one of the few neurological conditions where dysphagia alone may be the first symptom.

Aetiology of dysphagia

Benign causes

  • Benign head and neck tumours
  • Tonsillar hypertrophy, cervical spine osteophyte
  • Oesophagitis and narrowing caused by gastroesophageal reflux disease (GERD)
  • Upper oesophageal sphincter spasm
  • Thyroid tumour, thyroid hyperplasia
  • Oesophageal diverticulum
  • Congenital oesophageal rings
  • Cicatricial oesophageal stricture caused by a corrosive injury
  • Motility disorders of the oesophagus (achalasia, diffuse spasm, nutcracker oesophagus)
    • The most common cause for oesophageal dilatation is achalasia (impaired opening of the lower oesophageal sphincter combined with a motility disorder of the body of the oesophagus).
  • Systemic diseases that impair oesophageal motility (scleroderma)
  • Large diaphragmatic hernia

Malignant causes

  • The most common symptoms of a pharyngeal tumour are dysphagia and a lump on the neck.
  • Cancer of the head and neck Cancers of the Head and Neck
  • Oesophageal cancer
  • Cancer of the cardia
  • Other intrathoracic cancers (lung cancer or pleural cancer)

Risk factors

  • Risk factors for pharyngeal and oesophageal squamous cell carcinoma are smoking, alcohol and, particularly, their combined consumption in excess.
  • The most important risk factors for adenocarcinoma are severe GERD of several years duration and Barrett's oesophagus.

Neurological causes

Aetiology of globus sensation

  • Often, no clear cause can be found for the symptom.
  • Muscular tension in the area (both anterior and posterior) of the neck due to, for example, work with a computer in a forward-bent position.
  • Psychological factors
  • Upper oesophageal sphincter spasm
  • Oesophageal acid reflux symptoms
  • Cervical spine osteophyte
  • Thyroid hyperplasia or tumour

Diagnosis

History

  • At what stage does swallowing stop: in the mouth, pharynx or oesophagus?
    • Globus sensation is usually only present when air is swallowed and the sensation is cleared by swallowing food.
  • Has the patient had oesophageal symptoms in the past and particularly symptoms of GERD (heartburn, regurgitation of stomach acids, pain on swallowing, diaphragmatic hernia)?
  • Was the appearance of symptoms preceded by a corrosive injury (medicines, accidental ingestion of a corrosive substance)?
  • Are the current symptoms worse than when they first appeared?
  • Does the patient have systemic symptoms, changes in overall health, weight loss?
  • Does the patient have other or neurological symptoms?
  • How long have the symptoms lasted?

Acute dysphagia

  • Severe pain, fever and signs of shock may suggest oesophageal perforation, which is a life-threatening condition (mortality 20-50%).
  • Severe upper abdominal or chest pain may suggest an incarcerated diaphragmatic hernia.
  • Acute dysphagia combined with signs of an infection: pharyngitis or pharyngeal abscess Sore Throat and Tonsillitis. The possibility of epiglottitis must be borne in mind when the patient presents with fever and worsening general condition Epiglottitis and Supraglottitis in an Adult.
  • If a foreign body or a large piece of food has become lodged in the oesophagus the cause for the lodgement should be determined.
  • When associated with neurological symptoms dysphagia may be suggestive of vertebrobasilar ischaemia. Other symptoms of disturbances to the posterior circulation include hemiparesis and unilateral sensory disturbances, vertigo, difficulty in speaking and diplopia.

Dysphagia that has lasted for several weeks or months

  • Dysphagia that develops slowly over a few weeks or months and is associated with weight loss is strongly suggestive of a tumour in an elderly person and may suggest achalasia or a narrowing caused by reflux disease in a younger person.
  • Severe pain of a short duration associated with the passage of a piece of food is suggestive of a developing oesophageal stricture (a malignancy or benign stricture).
  • If dysphagia is the only presenting symptom, the possibility of a motor neurone disease should also be considered; other neurological signs will lead to the diagnosis of these diseases.

Chronic dysphagia that has lasted for several years

  • Intermittent dysphagia lasting for over a year suggests a functional disorder of the oesophagus. The most common of these is achalasia.
  • Intermittent symptoms that do not seem to be related to the consistency of the swallowed food may indicate a psychogenic problem (e.g. anorexia, see Eating Disorders Among Children and Adolescents).
  • May be associated with advanced neurological diseases.

Investigations

Investigations in primary health care

  • Physical examination is the first-line investigation: inspection of the mouth and pharynx, palpation of the floor of the mouth, tongue and tonsils, palpation of the local lymph nodes and the neck, cranial nerve examination
  • Imaging and laboratory examinations as necessary.
  • Indirect laryngoscopy of the lower pharynx and larynx or fiberoscopy
  • If the patient is able to swallow normally and food seems to become stuck lower down, oesophago-gastroscopy is the examination of choice. Usually the macroscopic findings are enough to differentiate between a benign lesion (oesophagitis, stricture, diverticulum) and cancer as the cause of dysphagia. Histology will confirm the findings. Dilatation of the oesophagus suggests achalasia, but functional disorders cannot reliably be diagnosed by oesophagoscopy.

ENT and gastric surgery investigations

  • Nasolaryngoscopy carried out under local anaesthesia using a flexible fibre optic scope is an important investigation. Fibre optic endoscopic evaluation of swallowing (FEES) may also be carried out by an ENT specialist/phoniatrician. During the test a flexible scope is used to observe the progress of liquids of varying thicknesses through the mouth and pharynx.
  • Endoscopy of the hypopharynx and the upper oesophagus under general anaesthesia using a rigid scope is the investigation of choice, at least in patients whose dysphagia symptoms localise around the hypopharynx and when symptoms and other findings give rise to a strong suspicion of a malignancy.
  • In cases where it is not possible to achieve diagnosis with endoscopy, a double-contrast examination of the oesophagus is recommended (the videofluorographic test uses a fluoroscope to observe the progress of the swallowed barium substance from the oral cavity to the stomach).
  • If the cause of dysphagia is suspected to be in the oesophagus, an oesophagoscopy is needed.
  • If the symptoms of globus sensation persist, an ENT specialist should be consulted.
    • X-rays of the hypopharynx and oesophagus
    • If necessary, a hypopharyngo-oesophagoscopy under general anaesthesia using a rigid scope.
    • Ultrasound examination of the neck
  • Indications for radiographic examination of the oesophagus and stomach:
    • Oesophageal dilatation can only be reliably assessed with radiographic examination.
    • Radiographic examination is more reliable than endoscopy in the evaluation of the size and location of oesophageal diverticula.
    • Also useful in the evaluation of the size and type of a diaphragmatic hernia.
  • Manometry
    • Manometric measurement of oesophageal pressure used to analyse the motor function of the oesophageal body as well as the upper and lower oesophageal sphincters. The investigation is indicated where a functional disorder is suspected or when surgery is planned for GERD.
  • 24 hour oesophageal pH monitoring
    • An acid reflux into the oesophagus can be demonstrated.
    • If an oesophageal stricture with unknown aetiology is present (no history of typical acid reflux symptoms or corrosive injury), the degree of reflux can be determined, after the stricture has been dilated, by oesophageal pH monitoring.

Neurological investigations

  • If neurological dysphagia is suspected, the patient requires the expertise of a neurologist. Investigations are requested according to other neurological symptoms and physical examination.
  • Should there be grounds to suspect a central aetiology, MRI of the head is indicated. This may reveal the cause of both bulbar and pseudobulbar paresis.
  • Motor neurone disease and myasthenia gravis are principally diagnosed with an ENMG test.
  • In cases of suspected muscle disorder, the ENMG test may need to be complemented with other specialist investigations, such as muscle MRI and muscle biopsy.

Treatment , Treatment of Dysphagia in Long-Term, Chronic Muscle Disease

Oesophageal stricture

  • Endoscopic dilatation is the treatment of choice.
  • If the stricture is caused by GERD Gastro-Oesophageal Reflux Disease, the acid reflux is principally prevented with the use of medicines or, if necessary, with anti-reflux surgery.
  • Oesophageal dilatation can be repeated if necessary.

Carcinoma Preoperative Chemotherapy in Esophageal Carcinoma, Interventions for Dysphagia in Inoperable Oesophageal Cancer

  • In oesophageal cancer, the first line treatment consists of resection either alone or combined with cytotoxic drugs and possibly radiotherapy.
  • In head and neck cancer the treatment depends on the location of the tumour. The primary treatment for hypopharyngeal cancer is usually chemoradiotherapy.
  • In other cases the treatment is palliative. The treatment aims at keeping the oesophagus patent for eating. The insertion of an oesophageal stent is the most commonly used approach.

Disordered oesophageal motor function Endoscopic Pneumatic Dilation Versus Botulinum Toxin Injection in the Management of Primary Achalasia

  • Procedures that improve the patient's ability to eat in achalasia include endoscopic balloon dilatation of the lower oesophageal sphincter and the surgical incision of its muscles (Heller myotomy). Surgery is recommended for younger patients, balloon dilatation for others.
  • Diffuse oesophageal spasm and nutcracker oesophagus is treated with calcium channel blockers, such as nifedipine. If the symptoms are severe it is also possible to incise the oesophageal muscle layer.

Oesophageal diverticula

  • If the diverticulum is symptomatic (dysphagia or regurgitation) surgical resection is indicated.

Neurological diseases

  • See articles appropriate to each disease (links above).

Suspicion of globus sensation

    References

    • Järvenpää P, Laatikainen A, Roine RP et al. Symptom relief and health-related quality of life in globus patients: a prospective study. Logoped Phoniatr Vocol 2017;():1-6. [PubMed]
    • Dumper J, Mechor B, Chau J et al. Lansoprazole in globus pharyngeus: double-blind, randomized, placebo-controlled trial. J Otolaryngol Head Neck Surg 2008;37(5):657-63. [PubMed]