Role of flexible transnasal esophagoscopy and patient education in the management of globus pharyngeus

Journal of the Formosan Medical Association (2012) 111, 171e175

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ORIGINAL ARTICLE

Role of flexible transnasal esophagoscopy and patient education in the management of globus pharyngeus Chia-Chi Cheng a,b, Tuan-Jen Fang a,b, Ta-Jen Lee a,b, Li-Ang Lee a,b, Tsung-Ming Chen c, Chin-Kuo Chen a,b, Albert Re-Ming Yeh a,b, Hao-Chun Huang a,b, Han-Ren Hsiao a,b, Wanni Lin a,b, Ying-Ling Kuo d, Hseuh-Yu Li a,b,* a

The Department of Otolaryngology, Chang Gung Memorial Hospital, Taipei, Taiwan College of Medicine, Chang Gung University, Taoyuan, Taiwan c Taipei Medical University-Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan d The Department of Dermatology, Mackay Memorial Hospital, Taipei, Taiwan b

Received 24 November 2010; received in revised form 27 January 2011; accepted 9 February 2011

KEYWORDS flexible transnasal esophagoscopy; globus pharyngeus; patient education

Background/Purpose: Globus pharyngeus and dysphagia are common complaints of patients referred to ear, nose, and throat (ENT) clinics. We aimed to establish an efficient method to rule out the presence of malignancy in patients with globus pharyngeus and dysphagia. Methods: The use of flexible transnasal esophagoscopy (TNE) was evaluated in 30 patients with globus pharyngeus and 6 patients with dysphagia. The patients were immediately informed of the findings on TNE examination, and then treatments were planned. All patients were treated with lansoprazole for 2 weeks and provided education on lifestyle changes at the initial examination and at the 3-month follow-up. Results: The patients reported an improvement in symptoms of globus pharyngeus after treatment (p < 0.001). Follow-up TNE confirmed improvement with less dysphagia, erythema, and vocal cord edema evident (all p < 0.001). Conclusion: The use of TNE and patient education are efficient management strategies for patients with symptoms of globus pharyngeus and dysphagia. Copyright ª 2012, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved.

* Corresponding author. 5, Fu-Hsing Street, Kuei-Shan, Taoyuan County 33342, Taiwan, ROC. E-mail address: [email protected] (H.-Y. Li). 0929-6646/$ - see front matter Copyright ª 2012, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved. doi:10.1016/j.jfma.2011.02.003

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Introduction Globus pharyngeus accounts for approximately 4% of all referrals to the general ear, nose, and throat (ENT) outpatient department.1 Commonly experienced by middle-aged women, the symptoms of globus are nonspecific but often include the sensation of a lump in the throat. The symptoms are generally improved by swallowing solid food and are more pronounced when swallowing liquids. There does not appear to be an association with tobacco use, hoarseness, or weight loss.2 Historically, anxiety has often been associated with globus pharyngeus, and although this disorder is no longer considered “hysterical”,3 patients with globus pharyngeus scored higher on standard psychological questionnaires than the general population.4 Despite reports of an incidence of head and neck malignancy in patients with symptoms of globus pharyngeus as low as 0.72%,5 the fear of neoplasm leads many of these patients to visit one doctor or clinic after another until the cause of the symptoms can be established. Therefore, an efficient method to rule out the presence of malignancy in patients with globus pharyngeus would be of great value in ENT clinics. The optimal diagnostic approach remains controversial because of a lack of randomized controlled trials in the literature,6 but the use of flexible transnasal esophagoscopy (TNE) has gained acceptance.7,8 The use of TNE in Taiwan is not yet commonplace, and we are aware of only three ENT departments that have this technology.9e11 The main objective of this study was to evaluate the role of TNE in patients with symptoms of globus pharyngeus and dysphagia visiting an Otolaryngology Department in Taiwan. Specific emphasis was placed on the ability of TNE to rapidly examine patients and rule out the presence of pathology, which was expected to relieve their underlying anxiety, although anxiety was not an outcome measure. The patients were treated with the proton pump inhibitor (PPI) lansoprazole for 2 weeks and encouraged to adopt lifestyle modifications to minimize their symptoms.

Material and methods Patients A total of 30 consecutive patients with symptoms of a lump in the throat (globus pharyngeus) and 6 patients with symptoms of dysphagia scoring 2 or less according to the scoring scale defined below were enrolled in this study between July 2008 and August 2009 at the Otolaryngology Department of our Hospital, a tertiary center in Taiwan. Any patients who had a history of head and neck cancer or other obvious explanation for their globus pharyngeus, such as, obvious reflux esophagitis were excluded. There were 17 men and 19 women aged between 28 and 71 years (average 49.3  10.6 years). This study was approved by the ethics committee of Chang Gung Memorial Hospital and complied with the guidelines of the Declaration of Helsinki. The severity of each patient’s symptoms was assessed before and 3 months after examination. Subjective complaints were categorized according to a 4-point scale developed in-house: 0, none; 1, mild; 2, moderate; and 3, severe. In addition, the severity of dysphagia was scored

C.-C. Cheng et al. with another 4-point scale12 as follows: Grade 1: no clinical signs and symptoms of dysphagia; Grade 2: very mild dysphagia was suggested by clinical examination, but the patient never complained directly of dysphagia; Grade 3: the patient complained of dysphagia, and this was supported by other clinical signs; however, nonoral feeding was not necessary at the time of investigation; Grade 4: the patient had obvious clinical signs and symptoms of dysphagia, including aspiration, and dysphagia was severe enough to necessitate nonoral feeding. Scores were also determined for the erythematous changes of the arytenoids and edematous changes of the vocal cords according to the Reflux Finding Score.13 All 36 patients underwent transnasal endoscopy and assessment of symptom severity before treatment and at 3 months after treatment.

Transnasal endoscopy To eliminate any variability in examination technique, all of the TNE examinations were performed by the same physician with the same equipment. The technique we used was similar to that reported previously.10 After an overnight fast, patients received topical decongestive anesthesia with cotton pledgets that were soaked in a mixture of 0.1% epinephrine/2% xylocaine solution (1:4) and placed in their nasal cavities for 10 minutes. Two sprays of 10% xylocaine were administered to the oropharynx. None of the patients received conscious sedation. The patients were seated in an upright position for the endoscopic examination. An ultrathin endoscope (FB-15RBS; Pentax Medical Co. Ltd., Montvale, NJ, USA) with two-way angulation capability, a distal end of 4.8 mm in diameter, an insertion tube of 4.9 mm, a suction channel of 2 mm, and a total working length of 600 mm, was lubricated and passed into the nasal cavity either along the inferior meatus or between the middle and inferior turbinates. This instrument provided a 100 field of view with a 3- to 50-mm depth of field. The oropharyngeal structures (including the base of the tongue, vallecula, and bilateral tonsils), the laryngeal structures (including the supraglottis and vocal fold movements), and the hypopharyngeal structures (including the bilateral pyriform sinuses and their apex, arytenoids and post-cricoid area, and posterior hypopharyngeal wall) were all examined. After thorough evaluation, the endoscope was passed into the esophagus with air insufflation to examine the mucosa of the entire esophagus, the gastroesophageal junction, and the stomach for possible lesions.

Treatment and follow-up All 36 patients were treated with 30 mg of the PPI lansoprazole once daily for 2 weeks. Additionally, patient education was emphasized at the time of the initial examination and at the 3-month follow-up visit. Each patient received written educational material outlining his/her examination findings and treatment plan, as well as the importance of various lifestyle modifications that would improve his/her condition. These recommendations included vocal rest, stress reduction, smoking cessation, elimination of alcohol, treatment of underlying allergies,

An efficient management of globus pharyngeus

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elimination of snoring, and treatment for acid reflux if needed. Recommendations to increase humidity in the living environment and to increase fluid intake were also reviewed.

complaint of dysphagia remained unchanged after TNE, treatment with lansoprazole, and patient education. However, these patients’ subjective globus pharyngeus scales improved.

Statistical analysis

Discussion

The Wilcoxon signed-rank test was used to examine the variation after treatment, and the median and interquartile ranges (IQRs) were computed and shown for all data. A value of p < 0.05 was considered as statistically significant. All statistics were performed with SPSS 15.0 statistical software (SPSS Inc., Chicago, IL, USA).

Our results showed that the scores for dysphagia, erythema, and edematous vocal cords rated during TNE improved. In addition, the subjective globus pharyngeus scores improved after flexible TNE, a brief 2-week treatment with lansoprazole and/or recommendations for lifestyle modification in patients with symptoms of globus pharyngeus and dysphagia. Globus pharyngeus and dysphagia are common complaints, and patients with these symptoms are generally referred to ENT outpatient departments.14 Although one study found the incidence of cancer in patients with the globus sensation to be <1.0%,5 this symptom often creates anxiety regarding malignancy for patients. Actually, most patients experience the symptoms of globus pharyngeus as a result of reflux disease and other common disorders that are not life-threatening. Nonetheless, it is important to be able to efficiently rule out the presence of malignancy and reassure patients. Although the optimal diagnostic approach remains controversial because of a lack of randomized controlled trials in the literature,6 the use of TNE in patients with globus pharyngeus has gained acceptance.7,8 Flexible TNE has several advantages over transoral flexible or rigid esophagoscopy. It is better tolerated by patients15 and, most importantly, TNE does not require patient sedation, which significantly minimizes the risk of complications.16 It can be performed as an inoffice procedure8 and, therefore, is ideal for efficiently evaluating patients with symptoms, such as globus pharyngeus.17 In one study, 89% of the patients with globus were examined with TNE and discharged in a single visit to the ENT clinic, thus avoiding the additional expense and time that would be required for contrast studies and rigid endoscopy.18 Globus is considered a symptom of laryngopharyngeal reflux and is part of the Reflux Symptom Index described by Belafsky et al.19 There is no standard protocol for managing this condition; and no controlled studies have evaluated the use of PPIs specifically for globus pharyngeus, although it is the primary symptom for which PPIs are prescribed.20 Any improvement that does occur in laryngopharyngeal symptoms after acid-suppression therapy has been shown to be slower than that in esophageal symptoms.20 Furthermore, several reports have asserted that most pharyngeal symptoms benefit very little from treatment with PPIs, probably because of the multifactorial etiology involved.21e23 A review of the literature concluded that randomized, controlled trials showed no significant improvement in the symptoms of laryngopharyngeal reflux after treatment with PPIs.24 However, the use of PPIs as a therapeutic test for patients with globus and a clinical diagnosis of laryngopharyngeal reflux has been recommended.25 Although we are aware that its use remains controversial, we prescribed PPIs in this study because laryngopharyngeal reflux is one of the possible causes of globus pharyngeus

Results The rate of successful nasal insertion was 100% in this study, and all of the patients completed the entire TNE examination. The procedure was well tolerated with only transient nausea during insertion of the endoscope and belching during air insufflation reported by some patients. One case of nasal bleeding occurred; and a few patients reported nasal pain after the examination, which resolved rapidly. No long-term complications occurred. No evidence of neoplasm was found in any of the patients after TNE; and none of the patients had obvious reflux esophagitis, although some had mild inflammation at the gastroesophageal junction. Variations in the scores for the subjective symptoms, the erythematous changes of the arytenoids, and edematous changes of the vocal cords after treatment are summarized in Table 1. The patients reported that their symptoms of globus pharyngeus improved after treatment (3.0 vs. 1.0, p < 0.001). The improvement was confirmed during TNE: erythema of the arytenoids was reduced in all 36 patients (3.0 vs. 1.0, p < 0.001). In addition, 12 of the 36 patients with mild edema of the vocal cords had no edema after treatment (p < 0.001). The dysphagia scores of 50% of the patients with the chief

Table 1 Scores for subjective globus pharyngeus scale, dysphagia, and erythematous and edematous changes before and after treatment among 36 patients with mild or moderate globus pharyngeus or dysphagia.a Before

After

Median (IQR)

Median (IQR)

p

Subjective globus 3.0 (2.0, 3.0) 1.0 (1.0, 2.0) <0.001* pharyngeus scale Scores rated during dDysphagia dErythema dEdematous vocal cords

TNE 2.0 (2.0, 2.0) 2.0 (1.0, 2.0) <0.001* 3.0 (0.0, 4.0) 1.0 (0.0, 3.0) <0.001* 1.0 (1.0, 2.0) 1.0 (0.0, 1.5) <0.001*

*Indicates significantly different after treatment, p < 0.05. IQR Z interquartile range; TNE Z flexible transnasal esophagoscopy. a Wilcoxon signed-rank test was used.

174 and we wished to reduce our patients’ discomfort as much as possible. The examination by TNE did not play a role in the decision to treat with PPIs in this study, although, had the patients shown obvious reflux esophagitis, we would have initiated long-term treatment with a PPI. Because the cost of PPIs is not covered by health insurance in cases of laryngopharyngeal reflux in Taiwan, we prescribed them to the patients in this study for only 2 weeks. Although this brief treatment with PPIs may have benefited some of the patients whose symptoms were due to reflux, the therapy with PPIs was probably not the primary reason for the improvements we observed. The relief of symptoms in this study was rapid, and the duration of treatment was brief. We believe that the patients may have experienced a reduction in anxiety upon learning that there were neither neoplasms nor foreign bodies after the TNE examination and that this in addition to the recommended lifestyle changes was an important factor in the improved outcomes at the 3-month follow-up. Indeed, simple reassurance has been considered a mainstay of treatment in many patients with globus pharyngeus,6 and several longterm studies have shown that the symptoms improve or resolve in over half the patients with no treatment.26,27 For these reasons, we do not wish to imply that the benefit of a 2-week course of therapy with PPIs has been established by this study. This study was limited by the relatively short time of follow-up (3 months), by the use of the patients’ selfevaluations rather than a standard grading system for symptoms, and by the absence of a control group of patients or a comparator arm in which patients were examined with another test. Additionally, the study did not include any tools for the psychological analysis of the patients’ anxiety before and after treatment. Nevertheless, the objectives of the study, which were to evaluate the roles of TNE and patient education in efficiently managing their symptoms, were met. Our results support the increased use of TNE in Taiwan for the evaluation of patients with globus pharyngeus and dysphagia.

Conclusion Flexible TNE was efficiently used in an otolaryngology department to rapidly examine patients with globus pharyngeus and rule out the presence of neoplasms or foreign bodies. The results of the TNE examination may have relieved the patients’ anxiety, and treatment with PPIs and/or lifestyle changes minimized or eradicated their symptoms. These findings support a more widespread adoption of this technique in Taiwan.

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