Throat Discomfort: When to See an ENT Specialist - Otolaryngology

Dr. Ye Dawei reply Otolaryngology

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Subject: 1.
Chronic Pharyngitis.
2.
In the ENT outpatient clinic at Hsinchu Hospital, the condition that takes up the most time and involves the most patients is the so-called "globus sensation." Many patients claim that they have heard from friends and family that Dr.
Yeh from the ENT department at Hsinchu Hospital is the best at treating this condition, and some general practitioners even enthusiastically (or perhaps helplessly?) refer such patients to me.
I have always been unsure how to respond to such praise.
The last time I complimented my wife on being the best banana peeler I’ve ever seen, she promptly retaliated before I could finish my sentence.
For these patients, who "should" be adequately treated by frontline physicians, the reality is that they often end up "shopping" around for specialists without finding a cure.
It is necessary to properly introduce this condition.

Firstly, what troubles physicians is that these patients often cannot clearly articulate what discomfort they are experiencing.
Their complaints range from sensations of something being stuck, warmth, fullness, spiciness, roughness, pressure, burning, mucus sensation, foreign body sensation, feeling like something is lodged, or sometimes even like a bug is crawling...
In medical literature, this is described as a lump in the throat, globus hystericus, globus syndrome, pharyngeal neurosis, psycho-organic syndrome, etc.
To date, the etiology of this condition remains unclear, but it may be attributed to one or a combination of the following causes:
1) Local causes:
a.
Chronic pharyngitis: Patients may develop inflammation of the pharyngeal mucosa due to recurrent colds, poor work environments, or personal habits like smoking and drinking, leading to secretions.
This prompts them to swallow saliva in an attempt to alleviate discomfort, which paradoxically exacerbates dryness and creates a vicious cycle.

b.
Chronic hypertrophic rhinitis, deviated septum, chronic sinusitis: These nasal conditions may cause post-nasal drip that irritates the pharynx, and nasal congestion may lead to prolonged mouth breathing, both of which can cause congestion and inflammation of the pharyngeal mucosa.

c.
Enlarged lingual tonsils: The palatine tonsils are visible when the mouth is open, while the lingual tonsils are connected to the vallecula epiglottica below.
Therefore, not only can enlarged lingual tonsils cause discomfort, but any abnormal enlargement, elongation, or hardness of the epiglottis or its cartilage involved in swallowing can also lead to a sensation of a foreign body.

d.
Esophageal disorders: Conditions such as esophagitis, diverticula, incomplete relaxation, spasms, or various causes of gastroesophageal reflux can lead to a sensation of a foreign body in the throat.

e.
Bone disorders in the head and neck: Conditions like Eagle's syndrome, where the styloid process of the temporal bone is elongated, can irritate the glossopharyngeal nerve, while cervical spine deformities can stimulate the sympathetic nerves or directly compress soft tissues, leading to a sensation of a foreign body.

f.
Thyroid disorders: Enlargement or dysfunction of the thyroid gland may be related to the sensation of a foreign body.

2) Systemic causes: These can be categorized into three main areas: anemia (especially iron deficiency anemia), endocrine disorders, and autonomic nervous system dysregulation.
Middle-aged women should particularly be aware of the potential for anemia and endocrine disorders.

3) Psychological factors: Stressful life situations, anxiety, or "cancer phobia" stemming from friends or family members having cancer can also contribute to this condition.

When treating this condition, the physician's attitude is of utmost importance.
It is crucial not to hastily attribute psychological factors as the cause before the patient has fully expressed their medical history; patience in listening to the patient's description often reveals the answers within their history.
If the main complaint is not just discomfort when swallowing saliva but also includes dysphagia, odynophagia, or specific points of pain, a thorough examination to rule out various possible local organic lesions is necessary.
Conversely, if the only symptom is a slight sensation of a foreign body when swallowing saliva without other symptoms, it is more likely to be a functional disorder.

As previously mentioned, the etiology of this condition is unclear, and it may be one of the three categories or a combination thereof.
Similarly, even after confirming a diagnosis of a significant local organic lesion, one must not overlook the potential accompanying psychological factors; comprehensive, holistic care is essential to avoid becoming "disease-focused rather than patient-focused." We must recognize that a diagnosis lacking a holistic perspective is merely one-sided; likewise, a lack of in-depth differential diagnosis of local lesions leads to an incomplete understanding of the whole.
Our understanding of the objective world is built upon this endless cycle of "local-whole-local-whole..." differentiation, where both "local" and "whole" are merely experiential concepts.
Only by transcending this dichotomy of "local" and "whole" can we arrive at the rational concept of "the whole." This holistic way of thinking is the key to genuinely caring for patients and healing this condition.
I hope to encourage all frontline physicians (especially those who have kindly referred patients to me) to cultivate this skill together, so we may soon master this art.

3.
Should I see a gastroenterologist or an ENT specialist first? Either is fine.

Dr.
Yeh Da-Wei, Director of the ENT Department, Hsinchu Hospital.

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Reply Date: 2009/10/25