Russell Cathcart

Lump in the throat.

Globus pharyngeus – a sensory abnormality of the throat – is a common condition affecting 6% of the population at any one time. It affects more than twice as many women than it does men, and although there is no upper limit for age of presentation, it rarely occurs in the first 2 decades of life. Globus is a clinical diagnosis made on history taking and examination, and there are several points to be aware of during the consultation: • The characteristics of the presenting complaint show variability in terms of quality, site and intensity, not just between patients but also within patients. Although globus is classically described as ‘a ball in the throat’, it can equally be reported as the sensation of a hair or nut caught in the throat, as throat strain or swelling, or as a persistent throat itch. The affected area is usually indicated as being the back of the throat but it can lateralise, and although the intensity does also vary over time, it is overall non-progressive – a feature which should called upon to reassure patients about the benign nature of their symptoms. • This sensory abnormality leads to repeated dry swallowing and throat clearing, which in turn can perpetuate a mild dysphonia and/or throat discomfort (atypical globus). • The presence or absence of globus during swallowing is often used as a discriminating factor in differentiating globus pharyngeus from organic lesions, but it should be noted that up to 20% of patients with globus pharyngeus have persistence of their symptom during deglutination. Indeed for some patients, food can accentuate their awareness of their globus sensation. Conversely, others claim that food alleviates their symptom, and this can lead to weight gain. • Although upper aerodigestive tract malignancy is always a consideration in a person presenting with a lump in the throat, one should be aware that upper aerodigestive tract malignancy rarely, if ever, presents as a globus sensation alone. Inquire about associated symptoms, as the presence of dysphagia, aspiration, weight loss, pain and/or hoarseness greatly increases the likelihood of a malignancy being uncovered, especially in high risk patients (excess alcohol, smoking, >40 years). • Identify indicators of underlying anxiety. Although a long way from its former guise of globus hystericus, globus pharyngeus has been shown to be associated with increased levels of covert psychological distress, particularly amongst female sufferers. This tends to be in the domains of anxiety and affective disorders, but not, contrary to popular belief, related to emotion. There is a correlation between anxiety levels and throat scores, and the level of anxiety seems to be stable over longterm follow-up. • Globus pharyngeus patients are, on the whole, physically well patients with few other major co-morbidities. They are, however, more likely than other patients to have reported other medically unexplained symptoms to their general practitioner in the past, such as irritable bowel syndrome, abdominal pain, or headaches.

Night-to-night variation in snoring sound severity: one night studies are not reliable

Clin. Otolaryngol. 2010, 35, 198–203

Should chronic catarrh patients seen in primary care be referred for further investigations

Background:  Chronic catarrh is commonly encountered in primary care, but often presents a quandary to the clinician because the history of postnasal or pharyngeal mucus build‐up is frequently at odds with the absence of physical findings. As with certain other medically mysterious syndromes, the value of often costly investigation remains unclear in both the primary and the secondary care settings. Indeed, investigation may reassure the physician more than the patient ( 1 ) and could even prove counter‐productive through reinforcement of the patient’s belief about the presence of significant pathology ( 2 ).

The conversion from sensation to symptom – the case of catarrh, a qualitative study

Objective: There is significant variation in symptom tolerance before seeking healthcare advice and it has recently been postulated that there may be a similar variation in the degree to which individuals tolerate deviations in physiological body sensations before considering them symptoms. This study looked to explore this transition from sensation to symptom more closely using the clinical entity of chronic catarrh – a frequently presenting problem which represents a putative alteration of a physiological process. Design: Qualitative study using semi-structured interviews. Participants: 19 adult patients presenting with chronic catarrh, persistent throat clearing or post-nasal drip. Setting: Secondary care institute in North of England. Results: Subjects’ accounts revealed three changes in perception of nasopharyngeal mucus that triggered the transition from sensation to symptom: an apparent change in viscosity, quantity, or constancy. Such changes were invariably deemed to have a consequence (threat to wellbeing, social impact, or source of frustration) and invariably drew a response from the sufferer to limit these consequences. Conclusions: Symptoms representing an aberration of normal body sensations likely develop over time in a series of recognizable phases. Discriminatory markers appear to exist which delineate those body sensations accepted and those considered symptoms. These are discussed with the use of a novel symptom evolution pathway diagram.

Catarrh - the patient experience.

BACKGROUND No study to date has looked at the symptoms of chronic catarrh as defined by the patients themselves. We looked to explore the catarrh experience through the eyes of patients using a qualitative approach. METHODOLOGY/PRINCIPAL Forty-eight patients referred to Secondary Care with chronic catarrh, postnasal drip or persistent throat clearing completed an open-ended questionnaire from which a comprehensive symptom list was generated. Nineteen of these patients undertook semi-structured interviews to explore symptomatic themes relating to their catarrh using grounded theory analysis. RESULTS A standardised list of 38 catarrh-related symptoms was generated covering a wide topography. A common theme amongst interviewees was the frustration of being unable to expectorate mucus rather than expelling too much. CONCLUSIONS Difficulties exist in establishing whether the extensive list of symptoms associated with catarrh is a result of differing experiences for patients or simply differing lexicon describing the same experience. Many of these symptoms are not included in the most commonly used nose/throat symptom instruments. Furthermore a distinction should be made between patients with true rhinitis who expel mucus and those who present with apparent postnasal drip or throat clearing but who cannot expectorate, whose management ought be focused more on symptom-coping strategies rather than medication or investigation.

Catarrh: an evidence‐based approach to the 12 min consultation

1 Mucus clearance. One of the first aims in managing ‘catarrh’ patients should be to delineate those who have an evident overproduction of mucus [e.g. perennial rhinitis, nasal polyposis, chronic rhinosinusitis (CRS)] with those who instead describe the sensation of excess mucus. To this end, it is useful to ask whether or not they are able to expel their mucus, either by mouth or by nose. One of the overriding features in the history of those catarrh patients who prove refractory to standard medical treatments is that they are frequently unable to expectorate the mucus that they feel in their throat – whether it be viscous or watery – and if they do, it is often a miniscule amount. This leads to a pervasive sense of frustration to them. Similarly, although they commonly feel congested nasally, ‘ineffective noseblowing’ ranks highly among the symptoms that they themselves volunteer. The management of such patients with an apparent sensory abnormality is quite different to those with an evident organic cause of excess mucus. 2 Duration of symptoms. Although the majority of chronic catarrh sufferers have put up with their symptoms for many years before seeking help for it, it is still helpful to establish just how long this has been, for there does appear to be a difference in expectation of the outcome of the clinical encounter between ‘short-term’ sufferers (up to 3 years in catarrh terms) and long term sufferers (10 years – lifelong) as will be discussed later. 3 Response. An important step in the transition of a body sensation into a symptom is that the patient will mount a response to the perceived aberrant sensation. This can range from simple dietary changes or avoidance of certain social situations which they feel exacerbate their symptoms, through to – in the more extreme cases – periods spent every morning retching up phlegm. Ascertaining each patient’s level of response provides an indication of their belief about the severity of their problem and can prove helpful in guiding later management, as again will be discussed later. 4 Associated symptoms. Enquire about associated symptoms which may imply an organic cause, such as sneezing ⁄ eye-watering, nasal blockage (not just nasal congestion), rhinorrhoea, or facial pain. Bear in mind, however, that due to its non-specific nature, catarrh is associated with a great variety of symptoms (an open-ended questionnaire completed by catarrh sufferers generated 34 associated symptoms that were reported on least two occasions) with each patient usually volunteering several of these. There does appear to be some pattern to this symptom reporting, however, as is evident when catarrh patients complete disease-specific symptom questionnaires.