High incidence of esophageal motor disorders in consecutive patients with globus sensation

GASTROENTEROLOGY

1991;101:1512-1521

High Incidence of Esophageal Motor Disorders in Consecutive Patients With Globus Sensation GABRIELE MOSER, GERDA VIKTORIA VACARIU-GRANSER, CHRISTA SCHNEIDER, THALIA-ANTHI ABATZI, PETER POKIESER, GISELHEID STACHER-JANOTTA, GABRIELE GAUPMANN, UTE WEBER, THOMAS WENZEL, MICHAEL RODEN, and GEORG STACHER Psychophysiology Unit, Departments of Psychiatry Divisions of Radiology and Clinical Endocrinology University of Vienna,-Vienna, Austria

Thirty consecutive patients with globus sensation who were referred to a psychosomatic clinic prospectively underwent otolaryngological, videokinematographic, and manometric examinations of pharynx and esophagus to evaluate whether morphological abnormalities or motility disorders underlay their symptom. When indicated by findings, M-hour pHmetry, scintigraphy of bolus transport, and esophagogastroscopy were performed. Seven patients were shown to have achalasia, 10 had “hypochalasia” (lower esophageal sphincter relaxation < 75% with esophageal contraction abnormalities but no complete distal aperistalsis), and 1 had diffise esophageal spasms; 2 patients had also hyperplastic lingual tonsils, 1 had tonsillitis, and 1 had a cervical spondylophyte. Nutcracker esophagus and nonspecific contraction abnormalities were found in 7 patients, and gastroesophageal reflux with esophagitis and a low lower esophageal sphincter resting pressure was found in 1; only 3 patients had normal esophageal motility. None had volunteered dysphagic symptoms at primary evaluation. Psychometric investigations in consenting patients showed no higher mean scores for state and trait anxiety, depression, hysteria, and hypochondriasis than in general medical outpatients. Esophageal motor disorders may, before giving rise to dysphagia, be sensed more vaguely and induce the globus sensation. However, only disappearance of the sensation after treatment allows inferring an etiological significance of such a disorder.

heterm

globus sensation is used to denote a sensation of a lump in the throat, which is associated with dry swallowing or the need for dry

T

and Surgery I; Psychosomatic Clinic and and Diabetology, Department of Medicine I,

swallowing, disappears completely during eating or drinking, and for which no organic cause can be established. In one study, globus sensation was found to be the most common initial complaint, i.e., of 4.1% of 4330 consecutive first-visit patients, in a general otolaryngological clinic (1). The symptom has been, and in some quarters still is, regarded to be psychogenic; hence the term “globus hystericus.” It was first mentioned in the Hippocratic treatises (2), and in 1794 the O$ord University Dictionmy defined it as “a choking sensation, as of a lump in the throat to which hysterical persons are subject.” In our century, the psychoanalyst Ferenczi was convinced that the globus sensation resulted from a “peripheral materialisation of a repressed idea . . . and a subconscious desire for oral sexual practices” (3). In 1949, Weiss and English (4) thought that “The hysterical symptom of swallowing over a lump is one of the most widely recognized indications of nervous illness,” and Glaser and Engel stated in 1977 (5) that the sensation represented “a physical manifestation of suppressed emotion, specifically, holding back tears.” Recently it has been proposed that the globus sensation is “a useful, single-symptom model for the study of conversion disorders” (6). However, this proposition was based on no more than the observation that 37 women with globus sensation had higher neuroticism and lower extraversion scores on the Eysenck Personality Inventory than 24 female “normal” controls of compa-

Abbreviations used in this puper: GER, gastroesophageal reflux: UES, upper esophageal sphincter: BDI, Beck Depression Inventory; STAI, Spielberger State-Trait Anxiety Inventory; MMPI; Minnesota Multiphasic Personality Inventory. o 1991 by the American Gastroenterological Association 0016-5065/91/$3.00

GLOBUS SENSATION

December 1993

rable age but otherwise unspecified characteristics. In contrast to these assumptions and claims, patients with the globus sensation were found to have no more hysterical traits than healthy persons (7-9) and otolaryngological outpatients with a wide variety of complaints (10,ll). Whereas the conception of a psychogenesis of the globus sensation remained purely hypothetical, a series of studies showed or suggested organic factors, such as cervical osteophytes (2,12), hyperplastic pharyngeal(2) and lingual tonsils (13,14), cervical lymphnodes (2), postcricoid webs (2), goiter (2), carcinoma on the base of the tongue (l3), and cervical arthrosis (15), as underlying the symptom. More distant disorders have also been found or suggested to be related with the sensation, e.g., hiatal hernias (2,16), duodenal ulcers and gastric lesions (2), esophageal or gastric carcinoma (17), diffuse esophageal spasm (18,19), achalasia (2,15), and an increased tension of the lower pharyngeal and cricopharyngeal muscles that is observed to prevail with the “inferior constrictor swallow” (14). In the last decades, gastroesophageal reflux (GER) (10,11,19-26) and/or a disordered contractile activity of the lower esophageal sphincter (LES) (2,19), the esophageal body (18,19), or the upper esophageal sphincter (UES) (2,10,11,27,28) have been held responsible for the globus sensation. However, there is considerable controversy on whether disorders of these types are in fact related to the symptoms of more than distinct proportions of patients (1,2933). The present study was aimed at prospectively determining whether somatic disorders and changes, in particular disorders of pharyngeal and esophageal motor function, GER, and morphological abnormalities in the neck, the pharynx and larynx, the esophagus, and the cervical and thoracic spine, were present in patients consecutively referred for globus sensation and could underlie the sensation. Furthermore, the study was aimed at investigating the patients’ psychological profile with respect to current and recent traits that might characterize the patients or be significant for the development and the course of their globus sensation.

Materials

and Methods

Thirty women consecutively referred under the diagnosis of globus sensation from October 1988 to June 1990 to the Psychosomatic Outpatient Clinic of the First Medical Department, University of Vienna, for further investigation were studied. The patients’ ages ranged from 24 to 67 years (median, 41 years), and the duration of their complaints ranged from 2 months to 22 years (median, 3 years). All had been referred as “problem cases.” Two patients came from general practioners, 2 each from an otolaryngological, a gastroenterological, and a psychiatric

AND ESOPHAGEAL MOTOR DISORDERS 1513

outpatient clinic, and the remaining 22 from a medical clinic at which they had been evaluated for suspected thyroid pathology. Twenty-seven had consulted more than one physician for their globus sensation. Therapeutic steps had been taken in 8 patients. They consisted of prescription of throat lozenges in 5 and of benzodiazepines in 3 cases. In no instance did these measures yield lasting beneficial effects, Before its initiation, the study had been approved by the Institutional Committee on Studies Involving Human Beings. At initial assessment, a detailed history, which also accounted for the patients’ psychological characteristics and psychosocial conditions, was obtained. In particular, past illnesses and the patients’ attitudes and behaviors associated with these illnesses were noted. Thereafter, patients were asked to complete self-rating scales aimed at quantifying current and recent feelings of depression and anxiety, i.e., the Beck Depression Inventory (BDI) (34) and the Spielberger Stait-Trait Anxiety Inventory (STAI) (35,36). Routine hematologic and biochemical screening was performed, and appointments were made for otolaryngological, fluoroscopic, and manometric evaluations. The rationale of the investigations and possible risks were explained to the patients. The otolaryngological examination was performed by two experienced investigators. It included a palpation and sonography of the neck to exclude enlarged lymph nodes, goiter, and other structural pathology and an inspection of pharynx and larynx using a flexible fiberoptic endoscope. The fluoroscopic evaluation consisted of anteroposterior and lateral double-contrast radiographs of the cervical region to provide information about the contours of pharynx, larynx, upper airways, and cervical spine in the resting state. The videoradiographic examination of pharyngoesophageal swallowing was performed with a frame rate of 24 per second and a Siemens Sirecord H tape recorder (Siemens AG, Erlangen, Germany]. Up to 10 swallows of 5-30 mL of liquid barium sulfate were obtained in each patient. Patients were instructed to hold the barium over the tongue and to swallow it as a single bolus when requested to do so. The examination included lateral projections centered on mesopharynx, hypopharynx, and UES region as well as anteroposterior projections, which centered on the valleculae and then followed the trailing edge of the barium swallow bolus until the stomach was reached. In the oral stage of swallowing, attention was paid to bolus control and tongue movement. In the pharyngeal stage, the excursions of velum, hyoid, and larynx were studied together with larynx closure, pharyngeal contraction wave, and UES opening. Finally, the movement of the bolus in, and the contractile activity of, the esophageal body were studied in the upright and the prone oblique position using boluses of low-density barium sulfate, which the patients were asked to swallow in a single gulp. During the entire examination, the posture of head and neck was observed to detect any attempt of postural compensation of disordered swallowing dynamics. The images of each swallow were analyzed during slow motion and frame-by-frame playback. The interpretation of pharyngeal mobility was based on criteria defined earlier (33, Before the manometric investigation, each subject under-

1514

MOSER ET AL.

went an interview and answered a questionnaire about symptoms and signs of gastrointestinal disorders. Both were directed particularly at symptoms of dysphagia, odynophagia, aerophagy, heartburn, retrosternal pain, postprandial fullness, regurgitation, vomiting, bloating, and epigastric and abdominal pain, as well as bowel habits. Thereafter, in an attempt to determine personality traits, the patients were asked to complete the Minnesota Multiphasic Personality Inventory (MMPI) (38) in its German 221-item short form (39). Individual raw MMPI scores were converted to T-scale scores, which are age and sex adjusted to normal reference populations and have a mean of 50 and a standard deviation of 10; T scores > 70, i.e., x + 2SD, are considered clinically abnormal. The manometric investigation of the contractile activity of the esophagus was performed with patients in a supine position and their head resting on a pillow to minimize head movement. A probe fitted with three strain gauge pressure sensors spaced at 5-cm intervals and oriented radially 120” apart (Konigsberg Instruments, Pasadena, CA) was used, the output of which was recorded on a Beckman R-411 Dynograph (Sensormedics, Anaheim, CA) using Beckman 9853A couplers. The amplified signals were digitized on-line at 30 Hz by means of a Hewlett-Packard 21MX E-series computer (Hewlett-Packard Co., Palo Alto, CA]. The initiation of swallowing was recorded by a surface electromyogram of the submental muscles. The resting pressure and the relaxation of the LES after swallowing were determined using the station pull-through technique drawing the probe at 5-mm steps in 30-second intervals. At each step, the resting pressure and the relaxation in response to the deglutition of 5 mL water at body temperature were measured using end-expiratory pressure with the mean fundic pressure as zero reference. The maximal resting pressures recorded by each of the three sensors and the residual sphincter pressures during the swallow relaxation at that point were averaged and expressed as mean peak resting pressure and mean residual pressure. For the evaluation of the contractile activity of the esophageal body, the probe was withdrawn at l-cm steps and 30-second intervals. At each step, the patient swallowed 5 mL of water. Pressures were analyzed using a computer program that determined the mean end-expiratory baseline pressure; the amplitude, duration, and propagation velocity of esophageal contractions; and the number of peaks per contraction wave. Amplitude was measured from the esophageal baseline to peak pressure, and duration was measured from the extrapolated onset of the rapid upstroke of the contraction to return to mean baseline. Contractions were classified as simultaneous when the peak recorded by two adjacent pressure sensors occurred at the same time. Double-peaked and multipeaked contractions were defined as contractions with consecutive peaks of at least IO mm Hg in amplitude and occurring at least 1 second apart from the previous peak. The contractile activity of the UES and its coordination with pharyngeal contractions was recorded drawing the probe at 5-mm steps in 30-second intervals. At each step, the resting pressure of the UES, the onset and duration of UES relaxation in response to swallowing of 5 mL of water, and the residual UES pressure at maximal relaxation as well

GASTROENTEROLOGY

Vol. 101, No. 6

as amplitude and duration of the postrelaxation contraction were determined. If the peak of the pharyngeal contraction recorded 5 cm above the UES occurred during the middle two quarters of the UES relaxation, the pattern was classified as coordinated. For measurement in the pharyngoesophageal region, the mean intraesophageal pressure was used as zero reference. To corroborate manometric findings of an incompletely relaxing LES or contraction abnormalities of the esophageal body, patients were asked to undergo a scintigraphic study of bolus transport. The patient was positioned underneath a gamma camera linked to a computer. The field of the collimator was adjusted to include the esophagus and the stomach, and a radioactive marker was placed over the cricoid cartilage to mark the upper end of the esophagus. The patient then swallowed, in a single gulp, a IO-mL bolus of water labeled with 20 MBq of sYmTc-tin colloid. Radioactivity was counted at the rate of one frame every 0.5 seconds for 120 seconds. The patient was instructed not to swallow anymore during this period. Four regions of interest were chosen: one each over the upper, middle, and lower third of the esophageal body and one over the stomach. For each of these regions, a time activity curve was generated, which reflected the dynamics of bolus transit. If the symptoms or the fluoroscopic examination suggested the presence of pathological GER, an ambulatory 24-hour recording of esophageal pH was performed. The pH signal was recorded by means of a glass electrode with incorporated reference (Model LOT 440-M3; Ingold Meptechnik, Urdorf, Switzerland) and sampled at a rate of 0.125 Hz using a microprocessor-based portable digital recorder (40). The patients were instructed to press a button on the recorder as soon as they felt the globus sensation. The recorded data were transferred to a personal computer and analyzed using a dedicated software package. The interprandial, intraprandial, and periprandial portions of the recordings were analyzed separately. The following variables were calculated for the total time as well as for the time spent in the upright and supine positions: number of episodes with pH <4, percentage of time with pH ~4, and number of episodes with pH <4 and duration > 5 minutes. If there was an indication on pH-metry for pathological GER or on radiography for stricture, diverticula, or other morphological abnormality, the patients were asked to undergo an esophagogastroscopy with or without biopsy to establish the presence or absence of esophagitis or other pathology.

Results were sliding

Hematologic, biochemical, within normal limits in hiatal

hernias

were noted

and urine analyses all patients; small radiologically

in 12

patients. Otolaryngological, fluoroscopic, and manometric investigations were performed in every patient, scintigraphic studies of esophageal bolus transport in 9, 24-hour pH studies in 6, and a gastroesophagoscopy in 4. The location of the globus sensation was most commonly in the midline at the level of the thyroid or

December

GLOBUS

1991

the root of the neck. In 29 patients, the sensation was more pronounced at repetitive dry swallowing, whereas it was eased or absent during food ingestion in all cases. A sore throat, or the constant desire to clear the throat, was present in 22 patients. Fourteen patients described their sensation as more or less (Table 1).At the persistent and 16 as intermittent initial assessment, 18 patients stated that the symptom would arise or be more intense in situations in which they were exposed to anger, dispute, or stress (Table 1).Four of these patients (patients 12, 13, 17, and 20) and another 5 (patients 1, 22, 24-26) feared that the sensation was a symptom of a yet undetected serious disease. Twenty patients reported that the sensation was less disturbing in states of distraction and quiescence. When completing the questionnaire about symptoms and signs of gastrointestinal disorders, 21 patients (70%) indicated that they felt that their globus sensation arose or was aggravated during stress (Table 1).On the same questionnaire, 42 of 63 (78%) women with dysphagia (age, 19-67 years;

Table 1. Patient and Symptom Characteristics, Globus Patient no.

Age

Duration

(&)

lYJ.1

1

61

0.2

14

24

5

16

25

1.5

18

61

24 26 30 3

sensation

Psychometric

Interview

6

D Yes Yes No

48

0.5

P

49

3

P

35

1.2

P

47

2

P

D, F D No Yes No No Yes Yes Yes + D D Yes Yes Yes Yes + D Yes Yes D No Yes Yes + D Yes No Yes Yes Yes + D No

5

38

3

I

8

34

5

P

9

36

3

I

15

49

3

I

20

65

5

P

22

46

0.3

I

23

34

7

I

27

34

0.3

P

28

25

1.5

I

12

49

12

P

4

41

4

I

1.5

P

10

33 35

29 6

17

P

67

5

I

65

11

I

17

55

2

I

19

58

1

I

7

27

1.5

P

11

41

0.3

I

2

37

22

I

13

27

15

I

21

60

3

I

MOTOR

DISORDERS

1515

median, 49 years) referred for manometry and subsequently shown to have achalasia stated that their dysphagia was elicited or worsened by stress. The psychometric investigations could be completely performed in only 18 patients (Table 1). One patient (patient 6) refused to undergo any psychometric testing and 2 (patients 4 and 19) refused to complete the STAI and the MMPI. Because of language problems, BDI and STAI were not fully completed by 1 patient (patient 30) who, however, was able to complete the MMPI with a research assistant’s help. No psychometric testing could be performed in patients 1 and 18, who felt unable to spend the time required. For organizational reasons, the MMPI could not be administered to patients 2, 3, 11, 13, 15, and 29. The histories of individuals who refused psychometric testing and in whom no testing could be performed showed no psychological characteristics, attitudes, or behaviors that differentiated these patients from those who completed the psychometric inventories.

Main physical -finding

Stress-related Presence

AND ESOPHAGEAL

Main Physical Findings, and Psychometric Data

P P I P

25

SENSATION

Questionnaire Yes Yes Yes Yes Yes No No Yes Yes No Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes No

Achalasia Achalasia Achalasia Achalasia Achalasia Achalasia Achalasia Hypochalasia Hypochalasia Hypochalasia Hypochalasia Hypochalasia Hypochalasia Hypochalasia Hypochalasia Hypochalasia Hypochalasia DES Nutcracker Nutcracker Nutcracker Nutcracker NECA NECA NECA GER Low LESP Struma None None

P, persistent; I, intermittent; D, fear that globus is symptom of undetected serious DES, diffuse esophageal spasms; NECA, nonspecific esophageal contraction pressure; Hs, hypochondriasis; D, depression; Hy, conversion hysteria.

___-

data

STAI

MMPI

BDI

State

Trait

Hs

D

Hy

19 6 -

57 47

54

57

65

63

56

44

56

52

59

43

84

68

70

48 -

60 -

72

79

76

60

56

59

13 8 4 2

52

42

11 5

41

5

51

13

35

13 5 9

7 21 -

32

39

60

45

57

35

44

59

40

55

59

43

63

65

65

49

46 37

65

42

54

45

60

42

54

41

56

47

59

54

52

60

61

65

36

36

49

54

49

53

54 -

65

56

62

11 1

43

40

67

47

60

2

47

38

21

42

52 -

60 -

47 _

59 _

-

_

_

12

51

36 --

64

54

62

6

44

40

70

47

63

27

62

57

59

42

57

16

24

65

58

9

62

38

2

35

34

disease; F, fear of fungal infection (white and foamy saliva); abnormalities: LESP. lower esophageal sphincter resting

1516

MOSER ET AL.

The 26 patients who completed the BDI showed slightly lower depression scores than a group of 100 consecutive new referrals to a general medical and gastrointestinal outpatient clinic (41).Fourteen patients showed no signs of depression (scores < ll), and 8 showed only mild signs (scores from 11 to 19). Three (patients 2, 26, and 29) had signs of moderate and one (patient 11) of severe depression (Table 1). The 24 patients who completed the STAI had only slightly higher scores than a group of 222 healthy female students for anxiety as a personality trait [means + SEM, 45.2 + 1.6 and 41.7 f 0.6, respectively; Student’s t test for sample means, t (244)= 1.45, NS] as well as for anxiety as a state [means, 48.3 + 9.6 and 42.1 r 0.7, respectively; t (244)= 0.57,NS]. On the MMPI, which was completed by 19 patients, the validity scales-L (lie), F (validity), and K (correction)showed no elevations. The mean T scores on the clinical scales were higher than those of the normal reference population (39), but none was in the abnormal range of above 70. The highest mean T scores, which were recorded on the scales hypochondriasis (mean + SEM, 61.9 + 2.0), conversion hysteria (60.1 r 1.5), psychasthenia (56.1 + 2.1), and depression (53.3 f 2.41, were in the same range as those of a group of approximately 50,000 medical outpatients (42). From the latter sample, individuals requiring surgery or another form of inpatient care and patients referred primarily for psychiatric evaluation or treatment had been excluded. Six patients (patients 2,11,13, 24,26, and 29) scored high on one or more of the psychometric tests (Table 1). In general, the results of the psychometric investigations bore no relationship to the manometric findings or the duration of the symptoms. The manometric, scintigraphic, and pH-metric investigations showed that 27 of the 30 patients suffered from abnormalities of esophageal motor function or pathological gastroesophageal reflux, phenomena that could well be regarded as underlying their globus sensation (Table 1). Disordered pharyngoesophageal motor activity was not observed in any of the patients either videofluoroscopically or manometrically. During the manometric investigation, none of the patients experienced the globus sensation. Of the three patients with normal esophageal motor function, one (patient 2) had a small cold adenoma in her left thyroid lobe and a slight enlargement of the entire thyroid gland. On reevaluation she reported to occasionally have difficulties in getting meat through her throat. In the other two patients (patients 13 and 21), no abnormality of any sort could be found. At initial assessment, all three patients with normal esophageal motor function had described their globus sensation to be present intermittently. Seven patients were shown to have achalasia as

GASTROENTEROLOGY

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defined by a < 75% relaxation from the mean peak resting pressure of the LES after swallowing and a nonpropulsive motor activity prevailing in at least the lower two thirds of the esophageal body. To corroborate the manometric diagnosis, scintigraphic studies of bolus transport were performed in four patients (patients 18, 24, 26, and 30). In all of them, transit times were grossly prolonged, i.e., > 120, 26, 30, and 57 seconds, respectively, compared with transit times of
December 1993

GLOBUS SENSATION AND ESOPHAGEAL MOTOR DISORDERS

the referring physicians. The globus sensation disappeared in the two dilated patients (1 and 18)and in two (16 and 24) receiving nifedipine. In patients 26 and 30, the nifedipine medication had to be discontinued because of adverse side effects. In both patients, no other treatment effort was undertaken, and the globus sensation remained unchanged. Patient 14, who was not given any treatment, reported 5 months after initial assessment that her globus sensation had vanished. Ten patients were found to have “hypochalasia,” i.e., an achalatic LES associated with contraction abnormalities but no complete absence of propulsive swallow-initiated contractions in the lower two thirds of the esophageal body (Table 1). At primary evaluation, none of them had volunteered any symptom that could have been interpreted as indicative for dysphagia. Three (patients 15, 20, and 28) had swallowinduced contractions of high amplitude (> 190 mm Hg) and long duration (> 7 seconds) in the lower two thirds of their esophagus, which were double-peaked in patient 28, in patient 15 and partly nonpropulsive but none of them admitted to any dysphagic symptoms even after they were informed about their disordered esophageal motility. A markedly increased occurrence of not swallow-induced, nonpropulsive (tertiary) contractions was noted in patients 5, 8, and 27. Patient 27 had also partly nonpropulsive swallowinduced contractions in the aboral third of the esophagus and, from time to time, a feeling of retrosternal pressure, which she attributed to her slightly enlarged thyroid gland diagnosed 2 years earlier. Patient 8 had an enlarged lingual tonsil and chronic pharyngitis, and patient 5 had a cold adenoma in her right thyroid lobe. In patient 22, the swallow-induced contractions were repetitive in the middle third of the esophagus, and in patient 23, swallow-induced simultaneous contractions anteceded the propulsive waves. Of the remaining two patients, patient 9, who had doublepeaked swallow contractions, reported after the diagnosis of hypochalasia was made that she sometimes had the feeling that food got stuck behind her sternum, whereas patient 3, who had no contraction abnormalities in her esophageal body, admitted chewing very thoroughly because of a fear that the food could otherwise not pass readily through her gullet. Scintigraphic studies of bolus transport, which were performed in patients 20, 27, and 28 to corroborate the manometric diagnosis, showed markedly prolonged transit times, i.e., > 120, 58, and 29 seconds, respectively. In patient 23, a delayed bolus transport was found on videofluoroscopy. Four of the 10 patients had stated, at initial assessment, that their globus sensation was persistent, and the remaining six stated that it was intermittent. For therapy, the same recommendations were given

1517

as for the patients with achalasia. However, none of the patients in fact was given nifedipine or was dilated. Two patients, 3 and 20, improved after medication of an anticholinergic drug and a benzodiazepine, respectively. In the eight patients without any therapy, the globus sensation remained unchanged in four (patients 5,8, 23, and 27), became less disturbing in two (patients 15 and 22), and vanished in the remaining two (patients 9 and 28). The manometric criteria for diffuse esophageal spasm, i.e., simultaneous waves in response to more than 10% of wet swallows and the presence of simultaneous waves with three or more peaks, were met by one patient (patient 12). After the manometric study, she admitted to have experienced mild, passing attacks of pain behind her sternum but denied having dysphagic symptoms. At initial assessment, she had described her globus sensation as persistent. The radiological examination had shown no abnormalities except for a cervical spondylophyte narrowing the esophageal lumen by one-third. For treatment, nifedipine was recommended but not prescribed. Four patients were found to have nutcracker esophagus, i.e., propulsive swallow-induced contraction waves with amplitudes of > 190 mm Hg and durations of > 7 seconds in the distal half of the esophagus. On reevaluation after the manometric study, one of these patients (patient 29) admitted to occasionally having had the impression that a bolus did not “go down” properly and also episodes of retrosternal pain. Her contraction amplitudes reached a maximum of 277 mm Hg, and the durations reached a maximum of 15 seconds. Patient 4 reported that she always had been a slow eater and that she was used to drinking after nearly every bite because of her feeling that this was the only way to finish a meal as early as others. Her swallow contractions had maximum amplitudes of 240 mm Hg and maximum durations of 19 seconds. The two remaining patients (10 and 25) volunteered no dysphagic symptoms and no odynophagia. At initial assessment they had described their globus sensation as intermittent, whereas the former two had described it as persistent. Radiologically, abnormalities were not described in any of the four patients. For treatment, a trial with nifedipine was recommended. However, none of the patients were treated. Six months after manometry, two of them reported that their globus sensation was unchanged (patients 4 and 25), and one reported that her disorder had been “cured” by manometry (10). No information could be obtained from patient 29. Nonspecific esophageal contraction abnormalities were found in three patients. One (patient 6) had double- and triple-peaked nonpropulsive swallowinduced contractions in the lower two thirds of her esophageal body but no symptoms of dysphagia. The

1518

MOSERET AL.

other two (patients 17 and 19) reported symptoms indicative of dysphagia neither at primary evaluation nor at reevaluation after manometry. Both had partly nonpropulsive double-peaked contractions in the lower half, and patient 19 had also a high proportion (70%) of missed peristaltic sequences in the upper esophagus and a markedly increased prevalence of tertiary contractions. Radiologically, no abnormalities were found in these patients. At initial assessment, all three patients had described their globus sensation as being present intermittently. A treatment trial with nifedipine was recommended, but only patient 6 was treated accordingly. She did not observe any change of her globus sensation. In the other two patients, the sensation was less intensive and frequent than at initial assessment 2 and 6 months later, respectively. One patient (patient 7), who, at primary evaluation, admitted to no symptoms of gastroesophageal reflux, had a total percentage of time with pH <4 of 12% on &l-hour pH-metry and, on endoscopy, an esophagitis grade II (longitudinal, confluent, noncircumferential erosions extending distally from the mucosal transition zone) (43). On manometry, a low mean LES resting pressure of 6.7 mm Hg and a high number of double- and triple-peaked contractions with durations of up to 10 seconds and amplitudes of up to 120 mm Hg in the aboral one third of the esophageal body were found. At initial assessment, she had described her globus sensation as persistent. After treatment with sucralfate (Ulcogant; Merck, Darmstadt, Germany), her esophagitis healed and the globus sensation became less intense and occurred more rarely. In patient 11, who had described her globus sensation as intermittent, a low LES resting pressure of 12.7 mm Hg but no pathological reflux was found. On reexamination, she admitted that she experienced, on rare occasions, a slight burning sensation behind the sternum. This patient also had spondylosis deformans of the lower cervical spine and a slightly enlarged thyroid gland. Two months after initial assessment the patient reported that her globus sensation had vanished completely after she had started to sleep in a semirecumbent position.

Discussion The results of the present study suggest that esophageal motor disorders may underlie the globus sensation in a much greater proportion of patients than acknowledged up to now. Unlike in earlier studies, such relationships became more apparent in the current study, probably because of the fact that our patients had been referred for evaluation only after they had consulted other physicians. Thus, they may not be representative of other populations of patients suffering from the globus sensation, and it

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may not be justified to extrapolate the findings of the present study to all patients with the symptom. However, it is also possible that such relationships did not receive due attention in previous studies. This may have been caused by the absence, or the patients’ disregard, of symptoms of dysphagia, odynophagia, regurgitation, or heartburn, which was characteristic of the individuals of the present study. Moreover, in only 12 of the 27 patients in whom it had become obvious after manometry and scintigraphic assessment of esophageal bolus transport that the motor activity of the esophageal body and/or the LES was disordered, such symptoms albeit slight or occasional, could be shown after reevaluation. This might be caused by the fact that most of the patients had been seen by a number of physicians for their globus sensation only to be told that nothing was wrong with them “organically” and that their symptom was purely “functional” or “psychosomatic.” Consequently, the patients might have learned to regard their symptom as what it was classified by the doctors. However, there seemed to be a relationship between the patients’ description of their globus sensation at initial assessment and the severity of the motor disorder found to be present; 6 of the 7 patients with achalasia, 4 of the 10 with hypochalasia, 2 of the 4 with nutcracker esophagus, and the 2 with diffuse spasms and gastroesophageal reflux, respectively, described their sensation as persistent. By contrast, none of the patients with normal esophageal motility had her sensation persistently. A possible explanation for the fact that the symptoms were confined to the neck and that the patients failed to perceive, or to take seriously, symptoms of dysphagia, retrosternal pain, or heartburn comes from earlier studies showing that no less than 33% of patients shown to have an obstruction to swallowing in their lower esophagus pointed to the throat when asked to point to where they felt the lesion was (44,45). As early as in 1924, Jacobson (18)reported that in a patient who had no symptoms of dysphagia “moderate spasm of various portions” of the esophagus was present fluoroscopically with the experience of globus and that thick barium paste was held in the esophagus for lo-25 minutes after swallowing. In a recent study on 12 patients (32),it was found that the typical globus sensation could be elicited by the distension of a balloon in the middle and proximal esophagus in 6 and 10 cases, respectively. This suggests that, in a good proportion of patients, the globus sensation might represent a referred sensation and yield no more than misleading information on the nature and localization of the underlying disorder. An etiologic significance of the esophageal motor disorders found for the development of the globus sensation is suggested also by the responses of the, alas

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GLOBUS SENSATION AND ESOPHAGEAL MOTOR DISORDERS

only few, patients who received adequate treatment for the revealed disorder; the sensation vanished in the patients with achalasia treated with mechanic dilatation and nifedipine, respectively, and diminished in frequency and intensity in the patient with GER, treated with sucralfate. That disorders of the motor activity of the esophageal body underlie the globus sensation more often than acknowledged up to now is also suggested by the results of earlier investigations. In a study of 18 patients, 2 were found to have diffuse esophageal spasm and another 2 nonspecific contraction abnormalities (19); also, in a radiological investigation on over 300 patients complaining of feeling a lump in the throat but also of a difficulty in swallowing, an impaired esophageal clearance of fluid in the horizontal position was found to prevail in one third of cases (46). However, in other studies no increased incidence of abnormal contractile activity of the esophageal body has been found (3 1,33). The most significant finding in the patients of the present study is the high incidence of achalasia and “hypochalasia,” i.e., incomplete LES relaxation (< 75%), as in achalasia associated with contraction abnormalities but no complete absence of propulsive swallow-initiated contractions in the lower two thirds of the esophageal body. This may not so much be caused by the fact that achalasia is still widely underdiagnosed but mainly by the complete lack of symptoms volunteered by the patients and the lack of esophageal dilatation on fluoroscopy in most of the cases, which both could have given rise to the suspicion of achalasia and to appropriate diagnostic steps. However, early stages of achalasia may not, or may only intermittently (47), cause dysphagic symptoms; some patients may even have megaesophagus without symptoms (48). Remarkably, 6 of the 7 patients with achalasia and 4 of the 10 with “hypochalasia” had stated at initial assessment that their globus sensation was persistent. The type of motor disorders found suggests that the globus sensation is related to food remaining in the esophagus after a meal. This could explain the occurrence of the sensation mainly between meals and not during the, necessarily distracting, act of eating, in the course of which, because of the upright position and the pharyngeal pump, food may enter the stomach rather unhampered. In contrast to our study, other investigations reported only a small proportion of globus patients to have achalasia (2) or no cases of achalasia at all (31,33).The fact that in the present study focal transducers and the station pull-through technique were used to evaluate LES resting pressure and relaxation after swallowing, instead of the more reliable sleeve technique (49), does not mean that the diagnoses of achalasia and “hypochalasia” are question-

1519

able. Whereas a swallow-related axial movement of the esophagus over the recording probe may suggest sphincter relaxation in instances in which the transducer records in fact from the gastric or esophageal lumen, an incomplete or lacking relaxation cannot be simulated by axial movement. That none of the patients felt their globus sensation during the manometric investigation may have resulted from their attention being focused on the recording procedure rather than on the possible appearance of the sensation molesting them in their more private hours. The absence of pharyngeal and UES motor abnormalities in our patients is consonant with the results of earlier investigations that showed no (10,11,19,29) or only doubtful (33) abnormal features. The finding that only one of our patients had pathological GER and only one patient had a low LES resting pressure is in accordance with the results of an other study that also showed a low incidence of GER (31).Together, these data suggest that pharyngoesophageal motor disorders and abnormal esophageal acid exposure can not be considered as inducing the globus sensation in the great majority of patients suffering from that symptom. Although it could be expected that patients who accept a referral to a psychosomatic clinic are more inclined to report the presence of psychological factors in association with their disorder than general medical outpatients, no such tendency was observed in the patients of the present study who consented to be tested and in whom testing was not precluded for other reasons. In particular, there was no indication for an increased prevalence of depression and of heightened anxiety as a personality trait and as a state. Although the patients’ mean scores in the MMPI were higher than those of the normal reference population (39), the scores were in the same range as those of a large group of general medical outpatients (42). Personality traits such as hypochondriasis and depression seem to influence the decision to consult a physician, and elevated scores for these traits may, thus, be common for outpatients rather than be specific for patients with the globus sensation. This is also suggested by findings that patients with globus sensation did not differ, on the Crown-Crisp Experiential Index, from general otolaryngological outpatients (10,ll)and from healthy individuals (7)and had no more anxiety on the Manifest Anxiety Scale (7). However, other investigators reported that female patients with globus sensation had high levels of anxiety, depression, and somatic concern and did not differ on the Crown-Crisp Experiential Index from psychiatric outpatients, whereas men had scores similar to a group with no psychiauic symptoms (9). It also has been reported that patients with globus sensation had a “markedly” higher than average score

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GASTROENTEROLOGY Vol. 101, No. 6

MOSER ET AL.

on the hypochondria.& and depression scales of the MMPI (50) and that seven (sic!) patients with globus sensation had more state and trait anxiety on the STAI and more depression on the BDI than 13 healthy subjects (51). That all patients of the present study were women might partly be ascribed to a sexual prejudice of the referring doctors, because the globus sensation is commonly considered to be of “hysterical” origin, thus occurring mainly in females. Clouse and Lustman (52) have suggested that psychiatric illness is associated with a specific cluster of esophageal abnormalities, consisting of an increased amplitude and duration of contraction waves, an increased frequency of abnormal motor responses, and triple-peaked waves. However, in a more recent study the same investigators (53) were unable to differentiate, using a multidimensional psychometric inventory, subjects with contraction abnormalities from those without. The latter findings are consonant with those of the present study, in which no relationship could be identified between psychological and manometric or other physical findings. Together, the available data do not suggest that personality characteristics and mood states, in particular anxiety, depression, hypochondriasis, and hysteria, contribute to any significant extent to the exacerbation and the maintenance of the globus sensation. Although there may be patients who have globus in association with severe emotional symptoms, the presumption that all patients with the sensation must have it from an emotional cause is unjustified. The fact that the proportion of patients who felt that their globus sensation was elicited or aggravated by anger, dispute, or stress was not greater than the proportion of patients with dysphagia, who were subsequently diagnosed with achalasia, indicating that their dysphagia was elicited or worsened under such conditions, suggests that also stress cannot be regarded as a major factor contributing to the globus sensation. However, stress could interact with an organic disorder to produce symptoms, i.e., the globus sensation as well as dysphagia. It can be concluded that in patients with globus sensation whose complaints cannot be ascribed to an oropharyngeal or thyroid pathology and who do not respond to therapeutic measures directed against such disturbances, there should be a high suspicion of esophageal motor abnormality justifying an extensive diagnostic workup. The high incidence of esophageal motor abnormalities, mainly achalasia, found in the patients of the present study, together with the results of previous investigations in the symptoms of to patients with spasms (18) or other obstructions swallowing (44,45), suggest that such disorders may, before giving rise to dysphagia, be sensed more vaguely and induce the globus sensation. However, only the

disappearance of the sensation after treatment allows to infer an etiologic significance of a disorder of that kind. Motor abnormalities in the pharyngoesophageal segment and abnormal esophageal acid exposure do not seem to be major etiologic factors for the globus sensation. The data from the patients who could be tested psychometrically suggest that also psychological characteristics, in particularly depression, situational and general anxiety, hypochondriasis, hysteria, and stress, are unlikely to be of etiologic importance. The term “hystericus” must be avoided because it not only is a misnomer but also bears the temptation to refrain from searching for the sensation’s cause.

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Received October 16,199O. Accepted March 21, 1991. Address requests for reprints to: Georg Stacher, M.D., Psychophysiologisches Laboratorium, Psychiatrische Universitatsklinik, Wahringer Gurtel 18-20, A-1090 Wien, Austria. The authors are grateful to the Ludwig Boltzmann Institut ftir Hirnforschung (head, Professor G. Schnaberth, M.D.), Vienna, for their help in the analysis of the MMPI data.