RETROSPECTIVE STUDY CONCERNING PHARYNGEAL PARESTHESIAE IN THE PATIENTS HOSPTALIZED AT THE RECOVERY HOSPITAL OF IASI

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1 Medical interferences RETROSPECTIVE STUDY CONCERNING PHARYNGEAL PARESTHESIAE IN THE PATIENTS HOSPTALIZED AT THE RECOVERY HOSPITAL OF IASI Lumini]a R\dulescu 1, C.M. Mâr]u 2, V.D. Mâr]u 3 1. Ph.D. Lecturer, ENT Clinic, the Recovery Hospital, Gr.T.Popa University of Medicine and Pharmacy, Ia[i. 2. Ph.D. Student and Resident Physician - ENT, ENT Clinic, the Recovery Hospital, Gr.T.Popa University of Medicine and Pharmacy, Ia[i. 3. Ph.D. Professor, ENT Clinic, the Recovery Hospital, Gr.T.Popa University of Medicine and Pharmacy, Ia[i. Corresponding Author: MD. Lumini]a R\dulescu; lmradulescu@yahoo.com; Abstract The objective of this study is to precisely state the significance of pharyngeal paresthesiae (pharyngeal globus) in various circumstances and to establish the extent to which this symptom occurs in severe diseases. Material and method: We performed a retrospective study, having as subjects the patients hospitalized or examined in the ENT Clinic The Recovery Hospital of Iasi, in the period , for pharyngeal paresthesiae. Results and discussions: Following our study we identified 218 patients with pharyngeal paresthesiae, representing 4% of the cases in the clinic. We divided the patients into three groups, according to the results we obtained: group A patients (53.67%) with pharyngeal paresthesiae secondary to a locoregional pathology; group B patients (22.02%) with pharyngeal paresthesiae secondary to a system disease and group C patients (24.31%) in whom we did not identify any pathologies. Although most of the times they are a manifestation of some benign diseases, there are situations when pharyngeal paresthesiae are the expression of a malignant tumor in an incipient stage, thus requiring the patient s assessment and monitoring in time. When no objective modifications are found at the endoscopic and X-ray examination (barium swallow) of the patient, and in the absence of esophageal ph monitoring, which could confirm a potential gastro-esophageal reflux, a hygiene-dietetic and medical treatment with proton pump inhibitors is recommended. Conclusions. Pharyngeal paresthesiae are a frequently met symptom in clinical practice. In the performed study, we outlined the importance of a multidisciplinary approach of the deglutition disorders represented by the pharyngeal globus, induced by the great variety of the pathology in which this symptom is involved. Key words: pharyngeal paresthesiae, etiology Introduction Pharyngeal paresthesiae (pharyngeal globus) are part of the sensitive disorders of the pharynx, which manifest themselves subjectively under the form of a wide range of sensations, which may either appear in the absence of an identified objective cause or may have an exaggerated intensity in relation with the triggering factor. Subjectively, the patients have the following symptoms: the sensation of a foreign body in the pharynx (hair, sand, etc.), throat irritability, burning, lump sensation in the throat, small stings, constriction, sometimes even moderate or violent pain; the pain can be localized or irradiated towards the nostrils, ear, tip of the tongue or hyoid region. Frequently, the patients find it difficult to describe the symptoms, and sometimes they are obsessed with the existence, in the pharynx, of a severe disease, such as tuberculosis or cancer. The paresthesic sensations are sometimes soothed when swallowing food products and worsen when swallowing saliva. Nevertheless, we may at times find a pathologic substrate, and, almost always, there is disproportion between the degree of the local lesion and the exaggerated symptoms of the patients, who are generally in good physical health, without suffering from fever, asthenia or anorexia. The intensity of these symptoms is highly variable and that is why it is considered that, in most patients that do not have a pathologic substrate, the intensity of these symptoms could be correlated with a psychic disorder; this usually manifests itself in individuals aged between 40 and 60, in women at menopause, as well as in men, especially in psychasthenic or intellectually overstressed ones. A more recent hypothesis suggests that the gastroesophageal reflux is the cause of paresthesiae. Material and method The objective of this study is to precisely state the significance of pharyngeal paresthesiae 58 volume 13 issue 3 July / September 2009

2 RETROSPECTIVE STUDY CONCERNING PHARYNGEAL PARESTHESIAE IN THE PATIENTS HOSPTALIZED AT THE RECOVERY HOSPITAL OF IASI (pharyngeal globus) in various circumstances and to establish the extent to which this symptom occurs in severe diseases, and, in this context, the importance that must be granted to this manifestation. We performed a retrospective study, having as subjects the patients hospitalized or examined in the ENT Clinic The Recovery Hospital of Iasi, in the period , for pharyngeal paresthesiae. The data were collected from the patient s record according to a specific standard, which included the reasons of consultation, detailed anamnesis, objective modifications at the ENT examination, data concerning humor, biochemical, bacteriological and mycological analyses, and psychological assessment; in some cases these were completed by a set of additional investigations. We took into consideration the following criteria for the inclusion of the patients in the study: patient with disturbing subjective sensations at the pharynx level (oropharynx, hypopharynx), without an obvious pathological substrate to clinically demonstrate them at the patient s first examination, or with minimum modifications. In the category of disturbing sensations, we included the following: the sensation of foreign body, lump sensation in the throat, small intensity diffuse or localized pain, dryness or swallowing difficulty, constriction, burns, stings; these manifestations lasted for at least 6 weeks, were permanent or occurred in episodes, and the patients minimum age was 17. The data were collected from the patient s record according to a specific standard, which included the reasons of consultation, detailed anamnesis, objective modifications at the ENT examination, data concerning humor, biochemical, bacteriological and mycological analyses, and psychological assessment; in some cases these were completed by a set of additional investigations, such as: panendoscopy, accompanied or not by esophageal, laryngeal, pharyngeal, tonsil or lingual biopsy; cervical CT scans, styloid apophysis x-rays, cervical spine, barium swallow etc, thyroid echography and scintigraphy, allergology, neurologic, endocrine and internal medicine examinations etc. Results From the total of 218 patients, 136 were women (62.38%) and 82 were men (37.62%), 123 came from the urban, and 95 from the rural environment. The mean age was 54, with a maximum in the years old interval (41% of the patients). We divided the patients into three groups, according to the obtained results: group A included the patients (53.67%) with pharyngeal paresthesiae secondary to a locoregional pathology identified during the performed investigations (Table I); group B included the patients (22.02%) with pharyngeal paresthesiae secondary to a system disease which affected the deglutition function (Table II) and group C comprised the patients (24.31%) without an organic locoregional or general pathology (Table III). PHARYNX Anatomically Lingual tonsil hypertrophy 10 constitutional 11 Lingual thyroid 1 Inflammatory Acute pharyngealtonsillitis 38 Oropharyngeal candidiasis Pharyngeal keratosis 2 Intratonsillar cyst/ abscess 6 81 Tumorous Tonsil papilloma 1 Base of tongue cancer 2 6 Cancer of the pharynxtonsil 3 ESOPHAGUS Anatomically Gastroesophageal hernia 3 constitutional 7 Esophageal diverticule 4 Functional disorders Esophageal spasms 4 12 Gastro-esophageal reflux 8 Foreign bodies Tumors 1 Esophageal cancer 1 SKELETON Cervical spine 8 Cervicarthrosis 8 14 Styloid apophysis 6 Elongated styloid 6 TOTAL % Table I Group A of patients with loco-regional organic diseases Hematologic disorders Anemic syndrome 8 Medullary aplasia 1 Mineral deficiencies Hypocalcemia, hypomagnesemia 14 Neurologic disorders 7 Allergy 11 Metabolic disorders 5 Autoimmunity disorders Sjogren syndrome 1 Dermatomyositis 1 TOTAL % Table II Group B of patients with diseases at the level of some systems Without visible organic lesions % Table III Group C of patients without visible organic lesions Journal of Romanian Medical Dentistry 59

3 Lumini]a R\dulescu, C.M. Mâr]u, V.D. Mâr]u Discussions Normal deglutition is a complex process, made up of three stages: oral, pharyngeal and esophageal, involving several neuronal and muscular structures. The first stage (the oral stage) is voluntary and involves a transformation process of the food products in the semisolid food bolus via the trituration of the food products and their mixing with saliva. Once formed, the food bolus is positioned in the median segment of the tongue and pushed towards the oropharynx. When it reaches the level of the bottom of the tongue, the food bolus automatically triggers the pharyngeal stage. The pharyngeal, as well as the esophageal stage, occur automatically, with the participation of the pharyngeal and esophageal muscles, of the cortical and bulbar nerve centers and of the cranial nerves: V, VII, IX, X and XII. The second stage consists of the formation of some peristaltic waves that move, at a fast pace, towards the esophagus, providing the transportation of the food bolus. Concomitantly, the breathing stops in expiration and the respiratory tracts are protected via: the lifting and the positioning of the larynx under the bottom of the tongue, as well as the closing of the sphincters represented by the real vocal cords, the false vocal cords and the aryepiglottic folds and the moving downwards of the epiglottis. Another condition that must be met in order to guarantee an efficient protection of the respiratory tracts consists of the existence of an intact sensory innervation. The esophageal stage transports the food bolus from the level of the cricopharyngeal sphincter up to the level of the stomach, via the peristaltic contractions of the esophagus. Deglutition disorders are frequently met in clinical practice, accounting for up to 4% of the cases of patients coming for an ENT examination (1, 2). They usually manifest under the form of a lump or a foreign body in the throat, localized by the patient on the median segment, at the level of the cricoids. In order to be able to assess the importance of this symptomatology, it must be evaluated depending on the context in which it occurs. There are three distinct situations: 1. The patient cannot swallow the food products or the saliva, and routine examinations identify the presence of some suggestive modifications in relation to a inflammatory, tumorous disorder or a malformation situation met in patients belonging to group A. 2. The sensation of foreign body appears only when the patient swallows the saliva, the deglutition of the food products occurs in a natural way and specific investigations do not identify any modifications these characteristics correspond to the patients in group C. 3. The deglutition disorders appear during the ingestion of food products, but they are absent when the patient tries to swallow his saliva. The additional investigations do not identify any organic loco-regional modifications. The routine examination of the aero-digestive upper tracts consists of the bucco-pharyngoscopic examination of indirect laryngoscopy, panendoscopy and barium swallow. These maneuvers enable the identification of the inflammatory, tumorous or malformation modifications at the pharynx level, esophagus and adjacent structures (for example, cervical spine) (Table I) (3). Depending on the data collected during the anamnesis and on the data gathered during the clinical examination, the paraclinical examination will aim at confirming the diagnosis assumptions: the evaluation of the thyroid gland via echography or scintigraphy, the X-ray examination, in specific incidences, of the styloid apophysis, the sampling of secretions at the level of the oro or bucco-pharynx for the bacteriological exams, the sampling of biopsies etc. Over 53% of the patients who participated in the study group A experienced an organic or functional pathology of the pharynx (81 cases of %), followed by the esophagus (21.36%) and the cervical spine. The pharyngeal inflammatory disorders (54%) and the non tumorous esophageal pathology (20.51%) (motility disorders, esophageal hernia, pharyngoesophageal diverticule) prevailed. Among the oropharyngeal inflammations, oral candidiasis is the most frequent fungus infection met in humans, especially at extreme ages (4). In 20-75% of the cases, it is asymptomatic (5). The invasion 60 volume 13 issue 3 July / September 2009

4 RETROSPECTIVE STUDY CONCERNING PHARYNGEAL PARESTHESIAE IN THE PATIENTS HOSPTALIZED AT THE RECOVERY HOSPITAL OF IASI of the esophagus leads to the appearance of dysphagia and of local discomfort. When faced with cases of oral candidiasis, the physician must look for and treat the risk factors involved in the reoccurrence of the infection. The pharyngoesophageal diverticule is another cause which leads to the appearance of pharyngeal paresthesiae. The diverticules accompany the esophageal motility disorders which determine the increase of the intraluminal pressure. In this sense, the treatment of the motility disorders must be the main objective of the treatment, and the diverticulectomy will be used only in special cases (large diverticules, acute inflammations, fistulae or cancer accompanying the diverticule) (6). Among the underlying causes met in an unexpectedly high percentage (11.96%) it is worth mentioning the structural anomalies of the cervical spine and especially the Forestier syndrome (diffuse idiopathic skeletal hyperostosis) and the structural anomalies of the styloid apophysis Eagle s syndrome. As a matter of fact, specialized literature mentions that, even though it is, most of the times, asymptomatic, the Forestier syndrome primarily manifests itself via the appearance of a lump sensation in the throat. The radiological examination of the cervical spine emphasizes the presence of extensive ossification, with the formation of osteophytes at the level of the ligaments, tendons and fascias, especially at the level of the cervical spine (7, 8). As concerns Eagle s syndrome (syndrome of the elongated styloid), the pharyngeal foreign body sensation is accompanied by latero-cervical pain, which worsens during deglutition. Palpation and imagery help in setting up the diagnosis (9, 10). At the opposite pole there are rarer diseases that accompany pharyngeal paresthesiae. Among these, it is worth mentioning the malignant tumor formations, which, although they seldom manifest themselves via pharyngeal paresthesiae, catch our attention due to their significance from the viewpoint of their severity and prognosis. In 5 (4.27%) of the patients in group A, accounting for 1.83% of the total number of patients who participated to the study, we identified the presence of some malignant tumors in incipient stages. Authors such as Amir (1999) noticed that, in 12% of the patients with malignant tumors of the upper aerodigestive tracts, the first symptom is the lump sensation in the throat (11). A small part (22.02%) of the patients with pharyngeal paresthesiae patients belonging to group B - corresponds to the situation in which the deglutition disorders occur during the ingestion of food products, but are absent when the patient tries to swallow his saliva; moreover, additional investigations do not identify any locoregional organic lesions; nevertheless, specific modifications can be emphasized during the investigation of the various systems (Table II) (12,13). The foreign body sensation appears only when the patient swallows the saliva, the deglutition of the food products occurs normally and the specific investigations do not track any modifications these characteristics are specific to the patients in group C (Table III). These disorders are more frequent in women with a history of psychic traumas. Some patients state they feel pain at the level of a normal pharyngeal anatomic formation which they believe to be pathological. Until recently these cases were labeled, via exclusion, after a series of investigations, as globus pharyngeus, and, since this is a psychiatric disease, the patient was treated by a psychiatrist. In the 1980s Batch conducted a study with reference to this pathology, showing that the globus sensation is, in most cases, secondary to the gastroesophageal reflux (14). The performed study showed that women were affected more frequently than men. Batch supported his theory with the help of a series of investigations that included: flexible endoscopy, biopsy which offer the possibility of the histological detection of the metaplasia associated with the Barrett esophagitis; in uncertain cases, the monitoring, for 24 hours, of the esophageal ph, gives the possibility of verifying and objectifying the reflux, the Bernstein test. He concluded that, in 60% of the patients, the pharyngeal globus is a distinct pathological entity and not a manifestation of a psychic disorder (14, 15). The Journal of Romanian Medical Dentistry 61

5 Lumini]a R\dulescu, C.M. Mâr]u, V.D. Mâr]u treatment primarily consists of keeping a hygiene-dietetic and medical regime with proton pump inhibitors for three months, twice a day, at minutes after the meals (16). In the event that no modifications are found during the endoscopic and radiological examination (barium swallow) of the patient and in the absence of esophageal ph monitoring, which might confirm a potential gastroesophageal reflux, the patient can be prescribed a hygiene-dietetic and medical treatment with proton pump inhibitors. Conclusions Pharyngeal paresthesiae are a frequently met symptom in clinical practice. Although most of the times they are a manifestation of some benign diseases, there are situations when pharyngeal paresthesiae are the expression of a malignant tumor in an incipient stage; given this possibility, the patient must be closely evaluated and monitored so that an eventual malignant process in its initial stage does not escape diagnosis. The wide variety of the pathology involving this symptom leads to the necessity of a multidisciplinary examination. References 1. Kyrmizakis DE, Panagiotaki I, Panayiotides J Lump sensation in the throat caused by tumors in the preepiglottic space. Auris Nasus Larynx 2003; 30(4): Motamed M, Murty GE Glossal palpation of the eustachian tube cushion: an unusual cause of globus sensation. Int J Clin Pract. 2001;55(1): Walther EK Deglutition disorders HNO 1998;46(8): Akpan A, Morgan R Oral candidiasis. Postgrad Med J 2002;78(922): Abu_Elteen KH, Abu_Alteen RM The prevalence of candida albicans populations in the mouths of complete denture wearers.newmicrobiol 1998; 21: Mulder DG, Rosenkranz E, Denosten L Management of huge epiphrenic esophageal diverticule. Am J Surg 1989;157: Kasper D, Hermichen H, Köster R, Schultz-Coulon HJ Clinical manifestations of diffuse idiopathic skeletal hyperostosis (DISH) HNO. 2002;50 (11): Walther EK Deglutition disorders HNO 1998; 46(8): Gaul C, Kriwalski MS, Maurer P si al Eagle s syndrome: a rare case of facial pain and difficulties in swallowing Nervenarzt 2006; 77(4): Woolery WA The diagnostic challenge of styloid elongation (Eagle s syndrome) J Am Osteopath Assoc 1990;90(1): Amir Z, Kwan SY, Landes D Diagnostic delays in head and neck cancers. Eur J Cancer Care 1999; 8(4): Dray, Todd, et. al. Dysphagia caused by neurologic deficits. Otolaryngologic Clinics of North America 1998;31(3): Schechter, Gary Systemic causes of dysphagia in adults. Otolaryngologic Clinics of North America 1998;31(3): Group AJ. Globus pharyngeus (Part I). J Laryngol Otol 1988;102: Allescher HD Diagnosis of gastroesophageal reflux: Praxis 2002 ;91(18): Remacle M, Lawson G. Diagnosis and management of laryngopharyngeal reflux disease. Curr Opin Otolaryngol Head Neck Surg. 2006;14(3): volume 13 issue 3 July / September 2009