Lupine Publishers | Differential Contribution of Vestibular Evoked Myogenic Potentials for Diagnosis of Superior Semicircular Canal Dehiscence Syndrome

 Lupine Publishers | Journal of Otolaryngology

 

Abstract

Introduction: Superior semicircular canal dehiscence syndrome (SSCDS) is described as a disorder of the inner ear denoted by the absence of a bony covering, causing vestibular and auditory symptomatology. The vestibular evoked myogenic potentials (VEMPs) provide information regarding the vestibular function, which is useful in the diagnosis of vestibular disorders. Our aim is to assess the differential role of ocular VEMP (oVEMP) and cervical VEMP (cVEMP).

Methods: oVEMPs and cVEMPs were collected from four male and five female (64.5 ± 3.6 years old) with SSCDS validated by computerized axial tomography between 2017 and 2019. The neurophysiological assessment included the calculation of latency and amplitude of both the pathological ear (PE) and the healthy ear (HE) and the asymmetry ratio (AR) of both ears. A control group comprising 14 people without vestibular pathology and similar age was utilized.

Results: The control group fitted well to the Gaussian distribution. The most persistent symptom was vertigo, followed by hearing loss. One patient had bilateral SSCDS. The latency was higher for cVEMPs at PE but was not disparate for oVEMP latency. In contrast, amplitude was higher at PE than at HE for both tests. Nonetheless, AR was >34% in all oVEMPs, while there were only in two of eight cases for cVEMPs.

Conclusion: Though cVEMP abnormalities in amplitude may help to suspect the pathology, oVEMP is the most sensitive and strong test for the diagnosis of SSCDS. This technique is a rapid, reliable, inexpensive test without side effects and thus has a very vital use as a screening and follow-up test in SSCDS.

Keywords: cVEMP; Clinical Neurophysiology; Hearing loss; Nystagmus; oVEMPs; Vertigo; Vestibular disorders

Abbreviations: AR: Asymmetry Ratio; CT = Computed Tomography; IOM: Inferior Oblique Muscle; cVEMP: Cervical Vestibular Evoked Myogenic Potentials; HE: Healthy Ear; nHL: Normal Hearing Level; oVEMP: Ocular Vestibular Evoked Myogenic Potentials; PE: Pathological Ear; SCM: Sternocleidomastoid Muscle; SSCDS: Superior Semicircular Canal Dehiscence Syndrome; VEMP: Vestibular Evoked Myogenic Potentials

Introduction

Superior semicircular canal dehiscence syndrome (SSCDS) is described presently as a disorder of the inner ear [1], denoted by the absence of a bony covering of this canal [2]. This acts as a “third window” anomaly, modifying the physiological functions of the inner ear, which generate an abnormal transmission of vibration to the vestibular system, responsible for the clinical symptomatology, such as vertigo, nystagmus, oscillopsia, and disequilibrium prompted by loud sounds (Tullio phenomenon) [3,4]. Furthermore, the Valsalva maneuver stimulates shifts in the pressure of the middle or intracranial ear because of pressure changes in the external auditory canal (Hennebert sign). This medical entity may also emerge in various other several clinical expressions, such as conductive hearing loss with a normal stapedial reflex [5], autophony, and hyperacusis with increased sensitivity for bone conduction, otic fullness [6], and pulsatile tinnitus [7]. The gold standard to validate the presence of the superior semicircular canal dehiscence (SSCDS) is high-resolution computed tomography (CT) of the temporal bone [8,9]. Nevertheless, neurophysiological studies to evaluate vestibular function are also noted [10]. Vestibular evoked myogenic potentials (VEMPs) have been proven useful in the diagnosis of vestibular disorders. However, there has not been too much attention to the SSCDS. VEMPs are time-locked muscular responses prompted by an auditory stimulus and give indispensable information regarding the otolithic organs (utricle and saccule), nerves, and vestibular nuclei (Figure 1) [11,12]. Ocular vestibular evoked myogenic potentials (oVEMPs) are ascending and excitatory utriculo-sacular responses that allow us to assess the integrity of the vestibular-ocular pathways [13,14]. On the other hand, cervical vestibular evoked myogenic potentials (cVEMPs) are descending and inhibitory saculocolic responses that give information regarding the vestibulospinal pathways [15]. The principal objective of this work was to evaluate the various roles of both types of VEMPs in the SSCDS. To give a useful as well as objective information, findings have been compared with a control group of people without vestibular pathology.

Figure 1: Neural pathways involved in VEMPs. The utricle-sacular pathway (red), which is valued with oVEMPs, is an excitatory and cross-pathway. The sacculal-colic pathway (blue) is an inhibitory and direct response, which is studied by cVEMPs.

Materials and Methods

Subjects

The study involved nine patients (four male and five female) with vestibular pathology, referred by an otolaryngologist that has a specialization in vestibular disorders (YLC), between 2017 and 2020 (Table 1). All of them had a diagnosis of SSCDS validated by CT. Furthermore, we conducted VEMPs among them and in a control group of 14 volunteers who had no vestibular pathology. The ethics committee of the Hospital Universitario La Princesa approved this study

Table 1: Demographic and clinical features of patients.

F: Female; M: Male; OF: Otic fullness. a: Caused by changes in the pressure; b: Caused by loud sounds; c: Espontáneous and caused by changes in the pressure.

Neurophysiological tests

VEMPs were obtained by means of a four-channel Neurosoft® system (Ivanovo, Russia) with specific software. Myogenic responses were procured via disposable surface electrodes (Ambu®, Ballerup, Denmark). Settings for oVEMP recording include the placement of the active electrode underneath the orbitary area, near the inferior oblique muscle (IOM), and 2 cm under the reference electrode. The ground electrode was put on the forehead (Figure 1). The patient was then instructed to stare ipsilateral upside to the auditory stimulus, the chin remaining straightforward. Responses were acquired in a bilateral manner [16]. Settings from cVEMPs include the placement of the active electrode in the middle of the ipsilateral sternocleidomastoid muscle (SCM) and the reference electrode at the upper part of the sternum (belly-tendon placement). During the test, the patient stayed in a supine position with the head lifted at 30° above the horizontal plane and rotated to the stimulated ear’s contralateral side (Figure 1). This response is because of the transient inhibition of muscle contraction [17-19]. Monaural acoustic stimulation was conducted via the headphones by means of 500 Hz bursts (100 dB nHL) and 6–8 ms duration at 5 Hz frequency. Masking white noise in the contralateral ear was utilized (−40 dB nHL). The bandwidth was 20 Hz–2 kHz, notch on (50 Hz). Two hundred stimuli were delivered, and signals were then averaged with a sampling rate of 20 kHz. The electrode resistivities were kept below 5 kΩ. At least two rounds for each test were conducted, with no pre-stimulus normalization. For oVEMPs, the latency was defined as the first negative deflection (n10), and, for cVEMPs, it was the first positive deflection (p13), where n is negative (upward deflection) and p is positive (downward deflection). The numbers refer to the time in ms. The amplitude (in μV) was calculated to be between p13–n23 for oVEMPs and cVEMPs, respectively. We also have measured the asymmetry between the amplitudes, wherein usually a significant symmetry is greater than 34% [20]. The asymmetry ratio (AR) was measured with the use of the following formula:

Where VEMP1 refers to the higher potential and VEMP2 to the lower one.

Pathological findings have been defined in accordance to a double criteria:

a) Own standard control tables acquired from people with no pathology and, also, as an additional control system, as seen in published tables [21,22], and

b) Furthermore the AR. Fiducial limits have been defined as mean ± 2.5 standard error of the mean (SEM) for our data and mean ± 2.5 standard error for published data.

Imaging tests were conducted before VEMPs in five patients, and SSCDS has been validated using both tests. In the remaining cases, the pathological side was determined with VEMPs, and the diagnosis of SSCDS was then validated with the imaging test. We conducted an evaluation of the data with the use of responses from the pathological ear (PE) and the healthy ear (HE).

Statistical analysis

For the patient’s group, we categorized the sample into two groups:
a) The pathological ear (PE) and
b) The healthy ear (HE).
For the control group, both ears were considered to be nonpathological. Statistical comparisons between groups were
conducted with the use of Student’s t-test or analysis of variance (ANOVA) for data with normal distribution. Normality was assessed with the use of the Kolmogorov–Smirnov test. Mann–Whitney rank sum test or ANOVA on ranks was utilized when the data have no normal distribution. Sigma Stat® 3.5 software (Point Richmond, CA, USA) was employed for statistical analysis. The significance level was set at p = 0.05. Results are indicated as mean ± SEM, except where otherwise stipulated.

Results

Control group

We have obtained the control values from people with no vestibular pathology which are picked up from our environment. The mean age was 54.3 ± 3.9 years. Results are outlined in Table 2. As expected, the results from our control group were somewhat similar to the ones published. However, there was a slight increase in latency and decrease in amplitude for cVEMP, although in both cases no statistical significance was noted (Mann–Whitney rank test). It is interesting to note that median and mean values are very similar for most of the variables, insinuating that normality can be presumed and the common test behaves strongly. We evaluated the AR from our group as well. Results are indicated at the bottom row of Table 2. SD instead of SEM has been utilized to increase the fiducial boundaries. We have obtained an upper limit of almost 20%.

Table 2: Descriptive statistics for the control group.

IP25-75 Interpercentile range 25-75; * Correspond to SD; ** Upper limit of asymmetry ratio.

Patients group

The mean age was 64.5 ± 3.9 years, which is no different from the control group (Mann–Whitney rank test). CT of temporal bone validated the presence of SSCDS in all the patients. One of the patients was diagnosed with bilateral SSCDS (see subsequent text).
The most common clinical manifestations were as follows:
a) Vertigo in all patients due to changes in the pressure among four of them and due to exposure to an intense sound in one
b) Conductive hearing loss in seven patients and chronic disequilibrium in five patients.
We have pooled the neurophysiological findings from ten responses for PE (both ears picked up from the bilateral SSCDS) and eight responses for HE. Latency and amplitude values in oVEMPs and cVEMPs of both ears from patients with SSCDS are outlined in Table 3. Latencies overall considered either from PE or HE were between normal limits. In the case of oVEMPs, no differences were noted between both groups (9.8 ± 0.2/10.1 ± 0.4 ms for PE and HE, respectively; n.s paired Student t-test). Nonetheless, in the case of cVEMPs, the mean latency for PE was higher than for HE (13.7 ± 0.7/12.6 ± 0.8 ms, p = 0.023 paired Student t-test). However, amplitudes were always higher for PE, such as for oVEMPs (41.5 ± 8.3/6.4 ± 1.2 μV for PE/HE, p < 0.005 paired Student-t test) and cVEMPs (148.8 ± 39.4/87.2 ± 28.0 μV, p = 0.029, paired Student-t test). PE amplitudes were higher for oVEMP (p < 0.001, Mann– Whitney rank test) and cVEMP (p = 0.045, Mann–Whitney rank test) as well, compared to the control group, but values for HE were between the control limits. See Figure 2 for a typical example of unilateral SSCDS. AR was greater than 34% in all cases (8/8) for oVEMPs (pooled 62.8 ± 6.2%) but only 2/8 for cVEMPs (pooled 26.9 ± 10.7%). AR was < 34% in the case of the patient with bilateral SSCDS (12.2% for oVEMP and 32.3% for cVEMP). Thus, the sensitivity for oVEMPs was 100%, whereas the sensitivity for cVEMPs was only 25%. Figure 2 shows an example of a patient with left SSCDS. We evaluated the association between latencies and amplitudes using the least-squares fit, for either PE or HE, but no correlation was found.

Table 3: Neurophysiological features oVEMPs and cVEMPs in patients with SSCDS.

oVEMP: ocular vestibular evoked miogenic potential; cVEMP: cervical vestibular evoked miogenic potential; HE: healthy ear; PE: pathological ear.

Figure 2: Usual findings VEMPs in patient with left SSCDS. A1) Bilateral oVEMPs showing increase in amplitude at contralateral IOM, after left ear stimulation. A2) Bilateral cVEMPs showing increase at ipsilateral SCM response, after left ear stimulation.

Finally, a more detailed bilateral SSDCS case was shown here. The patient was a 77-year-old woman referred for sudden spontaneous disequilibrium prompted by a loud noise and progressive bilateral pseudo-conductive hearing loss predominantly in the left ear. VEMPs demonstrated a remarkable increased amplitude in the responses from both oVEMPs as regards the normal values from the standardized tables. An amplitude of 51.2 μV was recorded in the right ear, and an amplitude of 40.1 μV was recorded in the left ear. Both values were pathological, proposing the presence of SSCDS. This fact was validated by CT conducted a posteriori.

Discussion

The principal aim of our study was to evaluate the specific role for oVEMP and cVEMP in the diagnosis of SSCDS. We have shown that even though cVEMP anomalies in amplitude may help to suspect the pathology, oVEMP is the most sensitive and strong test for the diagnosis of this syndrome. SSCDS could be due to the modification of fluid dynamics, where dehiscence would act as a “third window” in the inner ear, thus reducing the resistivity of the vestibular system and the resistance to the transmission of pressure and sound [1,3]. Because of this, the high intensity of the movement of the perilymph would generate a greater stimulation of the receptors of the vestibular system, leading to an increase in the amplitude of the response [24]. Presently, there are no amplitude or latency values capable of defining SSCDS. Usually a decrease in amplitude is a commonly accepted criterion in the neurophysiological test for one to say that it is pathologic. However, in the case of a disturbance of the vestibular system, an abnormally large potential would show the presence of a mobile “third window” in the labyrinth, as in SSCDS. Increased latency from VEMPs is not common, and it is usually correlated with conduction abnormalities in the central nervous system, as in the case of patients impacted with multiple sclerosis (ME) [11,23]. An own control group has been utilized from the same population as patients. This is a recommendation in most of the neurophysiological tests but seldom conducted. Values for latencies and amplitudes are similar to those found in literature [13,14], which is not unexpected. What is slightly more surprising was the observation that most of the variables fitted well to a Gaussian distribution. We also determined that the upper limit for AR is lower than the commonly accepted 34%.

Nonetheless, this criterion to define pathology has not been used since we need a greater number of people to be more confident. There are various studies that describe the decrease of the threshold and the increase in the amplitude of VEMPs [25-27] or the use of high-frequency stimulation to elicit the n10 component of oVEMPs [28]. However, few studies have investigated the diagnostic value of the increased amplitude of the oVEMPs and the asymmetry ratio in the SSCDS [29,30]. It has been shown that a decreased threshold provides diagnostic value, but the determination of the threshold may be uncomfortable for the patient [30]. The recording and measuring of oVEMPs need less time and effort than measuring the thresholds for cVEMPs since, in the latter, the patient should be kept in an uncomfortable position more time than for oVEMP. It is essential to keep in mind then for these patients that an intense sound can trigger vestibular symptoms; thus, it is advisable to minimize the duration of the study. With this study, we can conclude that the increase in the amplitude of oVEMPs has a high diagnostic value in the SSCDS. However, cVEMPs have a lower sensitivity, and, therefore, testing them should not be done in some cases, decreasing the time of the test but maintaining the same efficacy

The VEMPs are well tolerated by the patient, fast, inexpensive, and without side effects, so it can be considered an outstanding screening test for SSCDS, and, besides, these tests are potentially useful for objective follow-up following the treatment. The chief limitation of our study is the number of patients; however, the results are strong and therefore open up the possibility of extending the spectrum of utility of these potentials for various neuro-otology disorders as well as monitoring the evolution of SSCDS.

Conflict of Interests

The authors have no conflict of interest.

Funding

This work was partially financed (L V-Z and JP) by a grant from the Ministerio de Sanidad FIS PI17/02193 and was partially supported by FEDER (Fonds Europeen de Developpement Economique etc. Regional).

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Lupine Publishers | Rare Causes for Foreign Body Sensation in Throat: When Old Outlook Meets New Novelty

 Lupine Publishers | Journal of Otolaryngology

Abstract

Introduction: Foreign body sensation in throat is one of the commonest presentations in ENT. It can be simple & easy to treat but at times can be complex & alarming. Here, is a study exploring the uncommon causes of this symptom which is taking over the charts clinically in the routine mundane of life.

Aims & Objectives: To ascertain rare causes for foreign body sensation in throat in all possible mediums and how patient’s ideologies sum up to instilled seeds of cancer in their minds.

Methodology: 196 patients with rare causes for foreign body sensation in the throat over a year was clinically assessed, evaluated & treated after analyzing the source for the condition.

Results: Nearly 40% of new novelty causes i.e., GERD & “EpiConTon” superseded old outlook causes with female preponderance and stress topping the list of risk factor.

Conclusion: Time is said to heal things but life at times could throw on us new challenges & consequences in this present changing trends and lifestyle. People should crave only for a healthy living and happy state of mind in this taxing and thorny life.

Keywords: Globus pharyngeus; Eagle’s syndrome; EpiConTon; Laryngopharyngeal reflux; foreign body sensation

Introduction

Foreign body sensation in the throat is a vague symptom at times, but can be an alarming sign as well. There are different perspectives to this symptomatology which can range from a simple Globus sensation syndrome to complicated, malignant Laryngeal mass. Though it looks as a simple presentation, it has diverse branches in a variety of fields of medicine that is yet to be explored or in the process of being discovered. Usual causes for this symptom have been come across on day to day basis and are treated accordingly [1]. In this study, I have tried to bring to focus the uncommon causes for foreign body sensation of throat which these days have become common. Plus, also to highlight & emphasis on one of the finding/ cause which I have encountered in patients nowadays when rest of the ENT examination seems within normal limits particularly in my short practical experience and exposure so far, that is “EpiConTon”. As I have not come across any such study done so far in my review of literature for foreign body sensation in the throat.

Aims & Objectives

a) To list out rare causes for foreign body sensation in the throat encountered at ENT OPD.
b) To group the rare causes based on which category they belong to.
c) To look for if these causes have an association with the neuropathic pain
d) To find out gender and age-group predilection of the causes that lead to this symptom.
e) To categories the risk factors which have synergism with these causes that lead to this symptom.

Objectives: To highlight the specifics and sometimes the “out of the box” approach for the various probable causes for foreign body sensation in the throat in Indian population as it is at times way beyond “mystery of malignancy”.

Materials & Methods

Study design: Descriptive study.

Place of study: This study was taken place at Subbaiah Institute of Medical Sciences (SUIMS), Shimoga, Karnataka which is a Tertiary Care Hospital.

Study period: 1 year (October 2018 to September 2019). Selection criteria: A random sample of 196 patients (pts) who consulted the ENT outpatient department with rare causes for foreign body sensation in the throat were clinically assessed and evaluated and a provisional diagnosis was made. Following which, necessary laboratory & radiological investigations were considered, based on which treatment protocols were executed in all the patients mainly conservatively.

Inclusion criteria

a) Only adults were considered for the study.

b) Age group included in this study was between 18 to 48 years.

Exclusion criteria

a) All usual causes for foreign body sensation in the throat were omitted from the study.

b) Age group excluded from the study were < 18 years & > 48 years of age.

c) Children were excluded from the study.

Procedure of the study

Over a period of 1 year, a random sample of 196 pts who consulted ENT OPD with rare causes for foreign body sensation in the throat were clinically evaluated after taking a detailed & thorough history as well as complete ENT Head & Neck examination. Foreign body sensation in the throat is one of the common symptomatology while presentation in ENT OPD. In this study, 4 rare causes for foreign body sensation in the throat were considered. They are Globus pharyngeus (GP), Laryngopharyngeal reflux (LPR) or Gastro-esophageal reflux disease (GERD), Eagle’s syndrome (ES) or Styalgia and “EpiConTon”: It is Epiglottis touch/ Connect the base of Tongue.

Epi ConTon: Epiglottis is the leaf like projection or flap which is present at the base of tongue normally. It has a very important role in the physiology of deglutition. It prevents food from entering the windpipe and lungs. During breathing, it stands open allowing air into the larynx. This terminology was given by me in this study to address this condition. This is the new found endoscopic picture by me during laryngoscope examination. Patients with this clinical presentation are seen especially in females presenting with foreign body sensation in the throat, diffuse pain all along the posterior 1/3 of tongue. I have not across of this finding incidentally while on laryngoscope examination in patients with Throat and Head & Neck complaints. This clinical finding is not being addressed in literature data by far. After a thorough Ear, Nose, Throat with Head and Neck examination, a probable diagnosis was made. Following which, necessary laboratory & radiological investigations were considered, based on which treatment protocols were executed in all the patients mainly conservative line of treatment was apt in this study.

Globus pharyngeus/ globus sensation syndrome: It is the persistent feeling of something lodged in the throat. All patients with Globus pharyngeus showed no abnormality on ENT examination. A complete and in depth history was taken from the patient especially personal history. Usually in patients with Globus sensation, they tend to have a gross emotional intensity and their symptoms are more or so related to this outbreak. They were directed towards complete hemogram test. Based on the results, treatment was been advised. Mainly dietary implementation+ lifestyle modifications+ advisory counselling were given to these patients. In treatment, Haematinics along with Multivitamins were prescribed and before the start 1 dose of anthelminthic was also given. In this case, reassurance to the patient plays a major and a very crucial role.

Gastro-esophageal reflux disease (GERD)/ laryngopharyngeal reflux disease (LPR)/ Acid reflux disease: It is a chronic disease when the bile flows back into the esophagus that causes irritation of the mucosal lining and thereby leading to symptomatology. While in GERD pts, mainly lifestyle adaptations with dietary changes were advised and for temporary relief, antacids were given. Most of the patients were advised to follow a routine dietary course to stay free of reflux symptoms. The patients were also asked to follow these modifications on routine basis for wanting things beyond temporary relief in their symptomatology. “Dwell in the twelve”, I have put up 12 points that the patient has to follow in their routine basis to overcome GERD. Judicious follow of these points has been found useful for Migraine as well. The 12 points are mentioned below in the discussion.

Eagle’s syndrome/ Styalgia/ Styloid syndrome/Stylohyoid syndrome: It is a rare sudden, sharp nerve like pain in the jaw region, Temporomandibular joint region, back of throat, base of tongue and which is triggered by swallow, movement of jaw, turning the neck. In Eagle’s syndrome, when this elongated styloid process impinges in the tonsillar fossa, pt. complains of foreign body sensation in the throat with in some neuropathic pain. Patient is explained about the condition. For pain relief, drugs given with combination of analgesics with sedatives such as Gabapentin with Tramadol, Pregabalin & Tryptomer. The doses are calculated as per the weight of the patient/ day basis. They are also advised to take Multivitamins along with the treatment. These medications are only for temporary relief and should not be taken on continuous basis to avoid from its prolonged side effects. Tonsillo-styloidectomy is the surgical procedure done, but only gives relief to the impingement caused by the styloid process with no relief from the neuropathic pain point of view. Hence, mostly patients are not advised surgical management as it very gross and painful postoperatively. Similarly pts with EpiConTon, they present with foreign body sensation in the throat, neuralgic pain. As mentioned above, the same treatment is given for neuralgic pain which is temporary relief. Usually, I do not suggest surgical management for such neuralgic pain. Some pts have responded to Injection of local anaesthesia like Lignocaine at the root of the nerve origin at the base of anterior pillar and also all along it for pain relief done on OPD basis. Here, injection is given to block the plexus of Glossopharyngeal nerve that is spread all along the posterior 1/3 of tongue and posterior pharyngeal wall. Injection is given at the root of the nerve origin as mentioned above. On follow up, patients showed good response to treatment provided to them. Psychological factors play a major role in these conditions. Increased reporting of stressful life events prior to development of symptoms have an exacerbation of symptoms during times of emotional intensity. Informed written consent were taken from the patients during the study period. Institutional Ethics Committee has given clearance before the start of the study.

Results

The results of the study are depicted below Figures 1-7.

Figure 1: Video Laryngoscope (indirect) view of the larynx in the OPD showing the larynx and also the epiglottis is seen touching the base of tongue-“EpiConTon”.

Figure 2: “Pie in 3D representation” showing encountered rare causes for foreign body sensation in the throat.

Figure 3: Showing the “3D cylinder depiction” of various categories represented for rare causes for foreign body sensation in the throat in this study. They are O+N: (GERD+ GP= 27, GERD+ES= 13, EpiConTon+ GP= 15, EpiConTon+ ES= 10), N+ N: (EpiConTon+ GERD= 12), O+O: (GP+ES= 11).

Figure 4: “Exploded doughnut depiction” shows if the rare causes considered in study for foreign body sensation in the throat are associated with the presence of neuropathic pain or not. “YES”: 106 (ES-16 + EpiConTon-29 + GERD with ES- 13 + GP with ES- 11 + EpiConTon with GP- 15 + EpiConTon with ES- 10 + EpiConTon with GERD- 12). “NO”: 127 (GP- 38 + GERD- 62 + GERD with GP- 27).

Figure 5: “3D Pyramid representation” of the gender predisposition of the patients in this study.

Figure 6: “Pie diagram” showing age-wise distribution of patients in this study.

Figure 7: Exploded doughnut representation showing the probable risk factors that could be associated with foreign body sensation in the throat.

Discussion

Foreign body sensation in the throat is an ambiguous symptom at times, but can be an alarming as well. There are different perspectives to this symptomatology which ranges from a meek Globus sensation syndrome to malignant Laryngeal mass. Though it looks as simple the clinical presentation, it has diverse branches of presentations among population. There are many aspects for it source of symptomatology which are yet to be explored and are in the process of discovery [2]. Usual causes for this symptom have been a day to day encounter in the ENT OPD. In this study, I have tried to bring to focus the uncommon causes for foreign body sensation of throat which these days have become common. 4 such unusual causes that have been seen very common in the ENT outpatient department in the hospital so far is considered in this study. Based on history & examination, diagnosis of Globus pharyngeus is made. Patients should be asked for how long are they facing this feeling and to describe it. The presenting complaint may be described in various ways like a lump or ball in the throat, sticky sensation in the throat, some vague swelling moving up and down the throat etc. The symptoms often come by and go but constant or worsening symptoms are more of concern. The location of symptoms and the region involved for this feeling is central and suprasternal [3-5].

Pain on swallowing is not typical of globus. Note down if any reflux symptoms, throat clearing, cough or hoarseness of voice. Consider anxiety and ask about other symptoms of psychological distress including other physical symptoms such as palpitations, poor sleep and feelings of panic. Although cancer very rarely presents as globus pharyngeus. It is important to ask about red flag symptoms such as persistent hoarseness of voice, progressive dysphagia or dysphagia for solids, pain on swallowing, haemoptysis and weight loss [6-8]. Patients consuming alcohol or tobacco in excess leading to worsening of globus pharyngeus must be considered for referral to secondary care. As in every consultation the patient’s notions, apprehensions and prospects should be considered as most of them are worried about cancer. In general practice, a full examination of the head and neck is important [1]. The neck should be examined for thyroid gland and cervical lymph nodes. Oral cavity & oropharynx should be considered for any ulcerations or asymmetric features, which may suggest malignancy. Nose should be examined for any sort of inflamed mucosa, polyps or pus, any post-nasal discharge which has to be considered as a cause for globus pharyngeus. An abnormal neck or oral examination should prompt urgent referral to secondary care [9]. Gastroesophageal reflux disease (GERD)/ Laryngopharyngeal reflux (LPR) occurs when contents from stomach frequently flows back into esophagus. The mucosal lining of the esophagus can get irritated and stimulated by the backlash or acid reflux of the gastric contents. It is also called acid regurgitation. It has now become the present day most common health concern in India due to urbane and deluxe lifestyle. It is very soon trending on the disease charts of occurrence due to the current regime picks [10,11].

Many people experience acid reflux from time and again these days. GERD is mild acid reflux that occurs weekly twice while moderate to severe acid reflux that occurs weekly once. Most people can manage the uneasiness of GERD with regime variations and over-the-counter medications. But few people with GERD may need stronger medical therapy to relieve them of their symptoms [12,13]. Common signs and symptoms: retrosternal sensation in the chest/ chest burn/ heartburn usually after eating, which might be worse at night, chest pain, dysphagia, reflux of gastric contents, sensation of lump in throat. If there is presence of acid reflux at night, then there may be: chronic cough, laryngitis, new or worsening asthma, disrupted sleep. Complications like esophageal stricture, esophageal ulcer, and Barrett’s oesophagus. All these patients have an increased risk of esophageal cancer [13]. GERD is found to be very common these days. In the present day, when minting money has become the prime focus, very often health takes a backseat which is ignored and neglected. Hence it is better to avoid the triggering factors as far as possible and provide relieving factors at the earliest. Adapting these lifestyle modifications or measures on day to day scenario, has brought in lots of health benefits which has indirectly brought in a positive impact in the way of living and improving the way of life [14,15]. Following this sincerely on routine basis, can withhold and minimize the necessity of any medications if required and this can help lead a healthy and fit life. The points that fall under “dwell in the twelve” [16,17] are:

a) Avoid certain food such as- dark chocolates, cheese, caffeine, nicotine, egg whites, corn, sea food, citrus fruits, onions, artificial sweeteners & food colorings, sugary foods, red wine, alcohol, milk containing sweets, avocado, aerated drinks, any kind of fast food. Prefer foods rich in dietary fibers and natural sugars, all green & green leafy vegetables, cereals & pulses, dates, apples, milk.
b) Use fresh fruits and vegetables (avoid frozen foods).
c) Intake of food either solids/ liquids at frequent intervals in the form of small bites/ bouts with a gap of < 3 hours and eat mints instead of chewing gum. Do not skip meals (as in fasting / dieting/ intermittent fasting). Have timely intake of food (4 times/ day: 9AM, 1PM, 4.30PM, 8PM)
d) Avoid eating or eat less of spicy/ sour/ oily/ cold/sweet food stuff (do not use items directly out from fridge).
e) Do drink water before food (i.e. 15-20mins) is best and important rather than after food. Drink least of 3-4 liters of water / day.
f) Avoid /quit/ reduce smoke/ alcohol/ tobacco or gutka chewing/ supari etc.
g) Avoid stress as much as possible. Whenever stress hinders your path, try to change them if possible or else change the way you react to stress or find an alternative to face it and get rid of it in a nice way.
h) To relieve from stress- relax with meditation, guided imaginary yoga and divert focus on one task at a time. Taking up relaxing therapy to rejuvenate self and mind whenever possible- activities such as massage, painting, listening to music etc. (anything that makes you feel better and happy).
i) Reduce/ lose weight - either by hitting the gym or regular exercises (run or brisk walk for 45 minutes- 1 hour / day). Exercise 30 minutes 3 times a week to relieve distress/ stress and also to maintain healthy weight and body. Cut down on carbs and increase intake of proteins(less intake of rice and prefer roti’s/chapattis instead).
j) Sleep for adequate of 7-8 hours (have a regimented sleep pattern and do not lie down immediately post lunch or post dinner and stay awake for a minimum of 2 hours before going to bed or lying down especially during night times (when there is less chances of body exertion or exercise). Provide head end elevation of 15-30 degrees while asleep or during resting hours.
k) Try to avoid unnecessary intake of medications (as pharmacy outlets have become a “mini” hospitals to provide medications at their own will and wish).
l) Think and be positive in any possible situation, this is of utmost importance to lead a peaceful and healthy life.

Eagle syndrome is a rare condition characterized with sudden, sharp, shooting nerve-like pain in the jaw region, around temporomandibular joint area, back of the throat, base of the tongue and around ear, neck and /or face. Impingement or entanglement are stimulated as nerve connections have to pass through neck which seems the bridge between brain and body. This condition is caused by an elongated styloid process and/or calcification of stylohyoid ligament that interferes with functioning of neighboring regions in the body giving rise to pain. About 4% of the population have styalgia among them around 4% will give rise to symptoms Hence, the incidence of this syndrome may be about 0.16%. Patients with this syndrome fall under 30 and 50 years of age with male: female ratio ~ 1:2 [18,19]. This condition is also accompanied by dysphagia, foreign body sensation in the throat, pain is triggered on chewing, swallowing, turning neck on one side, touching the back of throat and movement of jaw. There can be association of tinnitus sometimes. Its classic presentation, is only on one side but can rarely present on both the sides. It could either occur spontaneously or can arise after birth. Usually normal stylohyoid process is 2. 5–3 cm in length, but length if longer than 3 cm, it is classified as an elongated styloid process [20,21]. In vascular type of Eagle syndrome, elongated styloid process comes in contact with internal carotid artery. Here, turning the head can cause compression of artery or a tear inside the vessel restricting blood flow and can potentially lead to a transient ischemic attack or stroke. Sometimes, it can compress internal jugular vein that can lead to increased intracranial pressure [22].

Diagnosis is suspected when a patient presents with symptoms of classic form that is unilateral neck pain, sore throat or tinnitus. Sometimes, tip of styloid process is palpable in the tonsillar bed. The diagnosis of the vascular type is more difficult and requires expertise. They can be relieved by infiltration of lidocaine into tonsillar bed. Because of close proximity of vascular structures in this area, this procedure should not be considered with much care [20,23]. Imaging is the diagnostic for styalgia other than clinical palpation. Picturing styloid process on 3D reconstructed CT scan is the suggested imaging technique. The enlarged styloid process may be also visible on an orthopantogram (OPG) or lateral soft tissue X ray neck or X-Ray neck( Towne’ s view) [22,24]. Partial styloidectomy is the preferred approach for any form of styalgia. In case to prevent neurological complications, repair of a damaged carotid artery is essential. Regrowth of the styloid process as well as relapse being a common occurrence is controversial. Medical management may include the use of analgesics with sedatives and anti-inflammatory medications, antidepressants, and/ or corticosteroids. The success rate for treatment (medical or surgical) is about 80% [18,21]. Among the rare causes for foreign body sensation in the throat in 233 pts, the top 3 causes based on the frequency of occurrence in this study are: GERD in 62 pts that is 27%, Globus pharyngeus in 38 pts that is 16% and EpiConTon in 29 pts that is 12%. So, among them the tendency for new category of causes among these 3 is nearly 40% pts. With changing trends and lifestyle reforms, new category of rare causes for foreign body sensation in the throat is seen taking over in the present scenario of population [25].

In this study, 5 different categories are formulated based on the rare causes for foreign body sensation in the throat. The 5 categories are: that is Old (O) and New (N).O (Globus pharyngeus (GP) & Eagle’s syndrome (ES), N (GERD & EpiConTon), O+N (GERD+ GP, GERD+ES, EpiConTon+ GP, EpiConTon+ ES), N+N (EpiConTon+ GERD) & O+O (GP+ES). Of which 91 pts belonged to New category that is in 39%, next is 65pts in O+N category that is in 28% and lastly 54 pts belong to Old category that is 23%. This shows that new category is having far more pts compared to the other category. This infers that the new generation outlook is making its way in this new aged modern era. Along with foreign body sensation in the throat, the next complaint was neuropathic pain. Neuropathic pain is continuous or episodic abnormal sensations from either a painful or non-painful stimuli that can occur as a result caused by the damage or disease affecting the somatosensory nervous system. It is different from neuralgia, as in it does not cause pain due to damaged or irritated nerve. In this study 45% showed presence of this pain among 106 pts and 55% showed no presence of pain among 55%. The ratio of yes: no for the presence of neuropathic pain is nearly 1:1. As there was no abnormality detected on ENT examination, except for these 2 complaints. Hence neuropathic pain presented as secondary symptom in this study. As only adults were considered for the study between age group of 18 to 48 years of age. Among them, 31% were males that is in 73 pts and 69% is females that is in 160 pts. The ratio of M: F is 1:2. Of the 3 categories of age group, 46% belonged to 28-38 years of age in 106 pts, 30% belonged to 38-48 years of age in 71 pts and 24% belonged to 18-28 years of age in 56 pts. The age group most affected is 28-38 years, where people are in the rat race to make money, leading a very stressful and unhealthy life, where in health is totally neglected and ignored.

Coming to the probable risk factors that could be encountered in this study where these reasons play a synergistic role that leads to this diagnosis. Among them, 37% showed stress to be the most probable risk factor in 87 pts. Next down the line are faulty and unhealthy eating habits/ dietary changes in 19% that is in 45 pts. While, the rest of the risk factors fall under < 13% of the total pts. These risk factors are additive in nature and always form the iceberg of any condition. Habitual consumption of spirit & smoke were purposely not accounted in the study, as actually it was not found to have any role to play in this study. As per literature search, I have not come across any such study which focuses on the rare causes for foreign body sensation in the throat. As apart from this, I have also come across “EpiConTon” in many of my patients which by far has not been reported in the data. This condition is one of a kind, as we all know that epiglottis which is normally present at the base of the tongue has its role in deglutition. But, epiglottis touching the posterior third of tongue not only stimulates the nerve pathway but has its effects that are not just limited to the base of tongue but also to posterior pharyngeal wall as well.

Conclusion

This study was mainly to introduce to the new encounter “EpiConTon” in my early practical experience in the field of medicine. This study was also to bring into light the uncommon causes of the common symptom “lump like” sensation in the throat which is taking the new plunge which is now presently encountered. To take out the notion from the minds of Indian population that even though there is no abnormality detected but still it is very essential to find the root cause for this symptom. It is not always “cancer” that is dreadful, but even this symptom can sometime be an alarming sign for some hidden critical situation. As the fact is known that Head and Neck cancer are one of the major reasons for mortality in India, due to which they end up with a consultation when this symptom is being encountered. Indian mentality is known to believe more of mouth to mouth bit over their self- experience. The only thing ticking in their minds is that while there is no compromise in their basic necessities in life such as respire, swallow and speech, then why is it still they are facing such a symptom. Plus, with the advent of science & technology, people prefer not just prefer “media popping”, “hospital hopping” along with “pharmacy shopping” till they are satisfied and convinced. So, these days along with the medications it is also become important to study the psychology of the patient and meet the needs of patient’s expectations over the experience & exposure that is actually attained by the health care takers.

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