What is the best approach to manage a patient with Hashimoto's thyroiditis and severe anxiety presenting with progressive dysphagia and throat constriction episodes?

Differential Diagnosis: Functional Dysphagia with Globus Pharyngeus

This presentation most likely represents functional dysphagia with globus pharyngeus, a disorder strongly associated with anxiety that manifests as throat constriction and swallowing difficulty despite normal structural findings. 1

Primary Diagnostic Considerations

Functional Dysphagia (Most Likely)

The combination of progressive dysphagia, throat constriction episodes, severe anxiety, and normal thyroid ultrasound strongly suggests functional dysphagia rather than structural thyroid pathology. 1

Key diagnostic features present in this case:

• Inability to swallow requiring warm water to "unlock" the throat is a classic positive sign of functional dysphagia 1
• Episodes occurring throughout the day and during sleep suggest functional rather than structural etiology 1
• Normal thyroid ultrasound excludes thyroid enlargement or structural compression 1
• Severe anxiety is a well-established comorbidity with functional dysphagia 1

Globus Pharyngeus (Highly Probable Co-occurrence)

Globus pharyngeus commonly co-occurs with functional dysphagia, with 20% of functional dysphagia patients experiencing globus sensation with swallowing. 1

Characteristic features:

• Recurrent sensation of throat tightening or choking 1
• Symptoms more obvious between meals but improve with eating 1
• Strong association with psychological stress and anxiety, with exacerbation during high emotional intensity 1
• Must be distinguished from true dysphagia, though both can coexist 1

Secondary Considerations

Hashimoto's Thyroiditis-Related Anxiety

The relationship between Hashimoto's thyroiditis and anxiety is bidirectional and well-established. 1, 2

• Euthyroid Hashimoto's patients have 2.5 times higher odds of anxiety disorders compared to controls (OR = 2.52,95% CI: 1.66-3.82) 2
• Thyroid antibodies themselves are associated with anxiety independent of thyroid hormone levels 2
• Nearly all studies found significant comorbidity between anxiety and thyroid disorders 1
• Blunted TSH responses to TRH administration and inverse relationship between anxiety levels and TSH have been documented 1

Thyroid Hormone Status Verification Needed

Despite normal ultrasound, thyroid function must be verified as subclinical hypothyroidism can present with anxiety and throat symptoms. 1

• Check TSH, free T4, and thyroid antibodies (TPO, thyroglobulin) 1
• If both adrenal insufficiency and hypothyroidism present, steroids must be started before thyroid hormone to avoid adrenal crisis 1

Diagnostic Workup Algorithm

Step 1: Exclude Structural Pathology

Instrumental assessment is warranted to confirm functional diagnosis and exclude organic causes:

• Videofluoroscopy (VFS) or fiberoptic endoscopic evaluation of swallowing (FEES) to identify positive functional signs 1
• Positive functional signs include: inability to swallow without drooling/excessive secretions, or inability to control anything in mouth but ability to spit saliva 1
• Biphasic esophagram has 95% sensitivity for detecting lower esophageal rings and strictures that may be missed on endoscopy 1

Step 2: Verify Thyroid Status

• Complete thyroid panel: TSH, free T4, TPO antibodies, thyroglobulin antibodies 1
• Ensure patient is biochemically euthyroid despite Hashimoto's diagnosis 2

Step 3: Assess Psychological Comorbidity

• Formal anxiety and depression screening using validated instruments 2
• Beck Anxiety Inventory and Beck Depression Inventory show significant elevations in Hashimoto's patients 2

Alternative Diagnoses to Exclude

Gastroesophageal Reflux Disease (GERD)

Globus must occur in the absence of GERD per Rome IV criteria. 1

• Consider trial of PPI therapy if GERD suspected 1
• GERD can cause throat symptoms but typically has different temporal pattern 1

Esophageal Motility Disorders

Videofluoroscopy has 80-89% sensitivity for diagnosing esophageal motility disorders compared to manometry. 1

• Achalasia and diffuse esophageal spasm can present with dysphagia 1
• However, the need for warm water to "unlock" throat and anxiety association favor functional etiology 1

Eosinophilic Esophagitis

Consider exclusion with distal, mid, and proximal esophageal biopsies if Schatzki's ring or refractory symptoms present. 1

Critical Clinical Pitfalls

Common avoidance behaviors in functional dysphagia can lead to unintended weight loss, social withdrawal, and worsening anxiety:

• Subtly reducing food intake and textures 1
• Changing head postures and eating slowly with raised bodily tension 1
• Social avoidance due to fear of choking 1
• These impacts on quality of life are similar to those in head and neck cancer patients 1

Do not dismiss symptoms as "purely psychological" without proper instrumental evaluation to identify positive functional signs. 1