Throat Notes from SCSOHNS 2023 in Myrtle Beach
For many patients, a “lump in the throat” or a chronic cough can dramatically affect their quality of life and overall health. At the 2023 North Carolina and South Carolina Societies of Otolaryngology-Head and Neck Surgery Annual Meeting, several clinicians presented on strategies for diagnosing and treating Globus sensation and neurogenic coughs.
Globus: Approaches to Evaluation and Management
Globus, “a persistent or intermittent non-painful sensation of a lump or foreign body in the throat,” has been confounding physicians since Hippocrates, observed keynote speaker Sandra Stinnett, MD. A “lump in the throat” can be difficult to treat, said Dr. Stinnett, a laryngologist who is Assistant Professor at University of Pittsburgh’s Department of Otolaryngology.
When a patient presents with a “lump in the throat,” a physician must first discern whether other symptoms are present that suggest conditions like a tumor in the neck. HPI red flags include pain when swallowing, weight loss, and vomiting, Dr. Stinnett said.
Some leading causes of globus sensation are GERD and Laryngopharyngeal Reflux (Silent Reflux). Dr. Stinnett mentioned Douglas J. Van Daele MD’s recent Laryngoscope article on diagnostic methods. Many patients with LPR respond to proton pump inhibitors PPIs, she told SCSOHNS attendees.
Dr. Stinnett compared more difficult-to-diagnose causes of globus to ‘Batman villains.’ To spot and fight his villains, Batman carries a well-supplied utility belt. Similarly, a laryngologist working to treat globus must carry a range of E/M options in her toolkit.
If the globus is the only symptom besides a chronic cough, you should explore whether the patient is dealing with a “visceral hypersensitivity,” Dr. Stinnett said. Sometimes, both upper esophageal sphincter (UES) dysfunction and globus are happening. She likened this situation to Bane, a Batman villain who revels in chaos. She has dubbed idiopathic globus pharyngeus ‘the Riddler.’
Cough Hypersensitivity Syndrome
Also called chronic cough, neurogenic cough, and unexplained cough, this condition is a cough some patients have endured for years because it doesn’t respond to treatments, noted SCSOHNS presenter Lyndsay Leigh Madden, DO, Associate Professor of Otolaryngology at Wake Forest University School of Medicine.
11% of Americans experience neurogenic cough, according to AAOHNS. Cough reflex hypersensitivity often starts with conditions like an upper respiratory infection, UACS, asthma, or GERD, but persists even after these conditions have been resolved. Often, these patients have other “throaty things” going on such as globus, Dr. Madden noted.
Long-term neurogenic cough impairs overall health and quality of life. Patients suffer urinary incontinence. More than 50 percent of patients have symptomatic clinical depression because their cough annoys the people around them, she said.
Dr. Madden referred meeting attendees to this 2016 ACCP treatment algorithm, and mentioned that sometimes patients with neurogenic cough respond to neuromodulating agents like gabapentin. In many cases, a referral to a speech language pathologist can help.
Also presenting was SLP Kathryn W. Ruckart, MS, CCC-SCP, a co-author with Dr. Madden on a paper describing the Laryngopharyngeal Measure of Perceived Sensation (LUMP) PROM.
How SLPs Can Help Quiet the Cough, ‘Bump the Lump’
SLPs have diagnostic methods and behavioral expertise that complement a laryngologist’s training, Dr. Madden pointed out.
An SLP is 60 minutes with each patient, which means they sometimes have time to dig down into life habits that a physician may not have had time to address—like how well the patient typically hydrates, Ruckart said. Sometimes globus pharyngeus is the result of a voice disorder that a trained SLP can hear when the patient speaks.
There are common themes to neurogenic coughs, Ruckart noted. Many start with a cough-inducing illness. Usually, they are daytime coughs and don’t happen during sleep. An SLP evaluating a chronic cough patient may do a voice evaluation to look for throat tension that may be causing cough sensitivity,
If the patient reports feeling a trickle in their throat before they cough, may be a good candidate for behavioral cough suppression therapy (BCST). Affordable and efficient, BCST improves cough severity in 87% of patients, according to a study that Ruckart cited. It’s a “respiratory retraining technique,” she explained. “As soon as they feel the tickle–in that half a second—they can learn to replace the cough with “sip breathing,” box breathing, or non-medicated cough drop to distract them from the sensation.
BCST involves exposing patients to common triggers for their cough and working with them on how to manage it. “What does the host of Hot Ones Host Have in Common with an SLP,” Ruckart quipped? “More than you think!”
Increasing surface hydration with steam inhalation or a portable ultrasonic nebulizer containing saline solution up to twice daily can also help.
