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
b
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

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 treat-
ment (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: doctorkevincheng@gmail.com (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
172
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 nonspe-
cific 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 malig-
nancy 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 sup-
ported 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 physi-
cian 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 exam-
ined. 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 lanso-
prazole 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
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.
Statistical analysis
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).
Results
The rate of successful nasal insertion was 100% in this study,
and all of the patients completed the entire TNE exami-
nation. The procedure was well tolerated with only tran-
sient 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 re-
ported 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 addi-
tion, 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 p improvement that does occur in laryngopharyngeal symp-
Median (IQR) Median (IQR)
Subjective globus 3.0 (2.0, 3.0) 1.0 (1.0, 2.0) <0.001*
pharyngeus scale
Scores rated during TNE
dDysphagia 2.0 (2.0, 2.0) 2.0 (1.0, 2.0) <0.001*
dErythema 3.0 (0.0, 4.0) 1.0 (0.0, 3.0) <0.001*
dEdematous 1.0 (1.0, 2.0) 1.0 (0.0, 1.5) <0.001*
vocal cords
*Indicates significantly different after treatment, p < 0.05.
IQR Z interquartile range; TNE Z flexible transnasal esoph-
agoscopy.
a prescribed PPIs in this study because laryngopharyngeal
Wilcoxon signed-rank test was used.
173
complaint of dysphagia remained unchanged after TNE,
treatment with lansoprazole, and patient education.
However, these patients’ subjective globus pharyngeus
scales improved.
Discussion
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 treat-
ment with lansoprazole and/or recommendations for life-
style modification in patients with symptoms of globus
pharyngeus and dysphagia.
Globus pharyngeus and dysphagia are common
complaints, and patients with these symptoms are gener-
ally 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 phar-
yngeus 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 in-
office procedure8 and, therefore, is ideal for efficiently
evaluating patients with symptoms, such as globus phar-
yngeus.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
toms after acid-suppression therapy has been shown to be
slower than that in esophageal symptoms.20 Furthermore,
several reports have asserted that most pharyngeal symp-
toms 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 lar-
yngopharyngeal reflux has been recommended.25 Although
we are aware that its use remains controversial, we
reflux is one of the possible causes of globus pharyngeus
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 exam-
ination and that this in addition to the recommended life-
style changes was an important factor in the improved
outcomes at the 3-month follow-up. Indeed, simple reas-
surance has been considered a mainstay of treatment in
many patients with globus pharyngeus,6 and several long-
term 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’ self-
evaluations 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. Neverthe-
less, 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 phar-
yngeus 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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