What diagnostic tests are recommended for a patient with dysphagia and globus sensation?

Diagnostic Tests for Dysphagia and Globus Sensation

For patients with dysphagia and globus sensation, a fluoroscopic examination is the primary diagnostic test of choice, with a biphasic esophagram being the most comprehensive initial imaging study. 1

Initial Evaluation

Clinical Assessment

• Assess specific symptoms:
  • Food sticking in throat
  • Sensation of lump in throat (globus)
  • Coughing/choking during swallowing
  • Nasal regurgitation
  • Difficulty initiating swallow 1
• Note that abnormalities in mid or distal esophagus can cause referred dysphagia to upper chest or pharynx 1
• Document onset, duration, association with eating/drinking, and presence of pain 2

Laboratory Tests

• Complete blood count (CBC)
• C-reactive protein (CRP)
• Blood gas analysis for base excess
• Lactate 1

Imaging Studies

First-Line Imaging

• Biphasic Esophagram:
  • Combines video fluoroscopy and static images
  • Evaluates both structural and functional abnormalities
  • Provides comprehensive assessment of oral cavity, pharynx, esophagus, and gastric cardia 1
  • Higher diagnostic value than either video fluoroscopy or static images alone 1

Alternative Fluoroscopic Options

• Modified Barium Swallow (MBS):

  • Performed with speech therapist
  • Focuses on oral cavity, pharynx, and cervical esophagus
  • Assesses bolus manipulation, tongue motion, hyoid/laryngeal/pharyngeal elevation
  • Particularly useful for evaluating oropharyngeal phase 1, 2
  • Gold standard for evaluating pharyngeal phase of swallowing (92% sensitivity, 80% specificity) 2

• Single-Contrast Esophagram:

  • Better suited for elderly, debilitated, or obese patients who cannot fully cooperate with biphasic examination 1
  • Less superior mucosal detail than double-contrast technique 1

Additional Imaging When Indicated

• CT Scan:

  • Not indicated as initial imaging (does not assess oropharyngeal/esophageal mucosa and motility)
  • Should be performed if perforation or other complications are suspected 1
  • Highly sensitive (90-100%) for detecting bone fragments when X-rays are negative 1

• Plain Radiographs:

  • Useful for assessing radiopaque objects
  • Limited value for food bolus impaction (false-negative rate up to 85%) 1

• Fiberoptic Endoscopic Evaluation of Swallowing (FEES):

  • Complementary to MBS
  • Can identify impaired chewing, tongue muscle deficit, laryngeal morphology and motility 2
  • Serves as an adjunct to modified barium swallow 3

Functional Assessment Tools

• Volume-Viscosity Swallow Test (V-VST):
  • High sensitivity (92%) and specificity (80%) compared to videofluoroscopy 2
• Eating Assessment Tool (EAT-10):
  • High discriminative capacity (sensitivity 86%, specificity 76%) 2
• Gugging Swallow Test (GUSS):
  • Recommended for evaluating dysphagia in neurological disorders 2

Specialized Tests When Initial Evaluation Is Inconclusive

• Esophagoscopy:

  • Consider when fluoroscopic studies are normal but symptoms persist
  • More sensitive for detecting hiatal hernia and esophagitis 4
  • Can rule out malignancy when suspected 4

• Esophageal Transit Scintigraphy:

  • Useful for assessing esophageal transit
  • Can detect motility abnormalities or gastroesophageal reflux 1
  • Not a substitute for examinations evaluating pharyngeal function 1

• Pharyngoesophageal Manometry:

  • Helpful for evaluating upper esophageal sphincter function
  • Particularly relevant in cases of cricopharyngeal achalasia 5

Important Considerations

• Avoid contrast swallow as initial test - should not delay other investigations/interventions 1

• Beware of misdiagnosis: 65% of patients previously diagnosed with "psychogenic dysphagia" or "globus hystericus" had documentable abnormalities on thorough evaluation 6

• Consider reflux evaluation: Laryngopharyngeal reflux disease (LPR) is a common cause of globus sensation and may require specific assessment of upper esophageal sphincter function 7

• Recognize limitations: Studies show that MBSS and esophagram for patients with globus sensation are often negative and may not add significant diagnostic information in uncomplicated cases 4

Diagnostic Algorithm

1. Begin with biphasic esophagram (first choice) or modified barium swallow
2. If initial imaging is normal but symptoms persist, proceed to:
   • Fiberoptic endoscopic evaluation of swallowing (FEES)
   • Esophagoscopy to rule out subtle mucosal lesions or reflux
3. For persistent unexplained symptoms, consider:
   • CT scan (if structural abnormality suspected)
   • Manometry (if motility disorder suspected)
   • pH monitoring (if reflux suspected)