Globus sensation

What is globus sensation?

Globus sensation is a subjective feeling of a lump or foreign body in the throat. It is sometimes called globus pharyngeus. The term globus hystericus was previously used because of the belief that psychogenic factors were involved and that globus sensation was just a type of somatisation disorder presenting with pseudoneurological symptoms. However, it is now widely considered that globus sensation can have underlying physiological or anatomical causes and there are thought to be a number of potential aetiologies.¹

Epidemiology ¹

Globus sensation is thought to be a common symptom experienced by up to 45% of the population. It accounts for 4% of new referrals to ear, nose and throat (ENT) outpatient clinics. There is no difference in prevalence between the sexes.

Globus sensation causes ¹

A multifactorial aetiology is likely. Suggested causes include:

• Gastro-oesophageal reflux disease. Reflux of gastric contents that may lead to irritation and inflammation of the laryngopharynx, or increased tone in the upper oesophageal sphincter that may be triggered by distention or acid in the distal oesophagus. In studies where acid is infused into the distal oesophagus, subjects describe a globus sensation. Studies haver reported reflux in up to two-thirds of those with globus, but some report a similar rate of reflux in asymptomatic patients, and not everyone with reflux experiences a globus sensation.²

• Raised upper oesophageal sphincter pressure.³

• Oesophageal motor disorders.

• Conditions causing irritation or inflammation of the pharynx - for example, pharyngitis, tonsillitis, and postnasal drip secondary to chronic sinusitis. It is thought that such problems lead to increased sensitivity of the pharynx.

• Hypertrophy of the base of the tongue.

• A retroverted epiglottis.

• Psychological factors. Some studies have shown that stress may exacerbate symptoms of globus. However, others have not supported psychological factors as a cause.

Globus sensation symptoms⁴

The symptom of a lump in the throat tends to come and go. It is usually felt in the front of the neck and can move up and down. It does not affect eating and drinking and in fact, symptoms may be alleviated by this. Symptoms are often noticed when swallowing saliva, yet not so severe when swallowing food or drink. There is no pain.

Careful history taking is important to try to differentiate between a globus sensation symptom and true dysphagia.

Examination should include:

• Examination of the neck - lumps, thyroid swelling, lymphadenopathy.

• Examination of the oropharynx - tongue base, floor of the mouth, mucosa, tonsils.

• Examination of the nose - hypertrophy, polyps, inflammation, discharge.

• Examination of the ear - if globus and otalgia but normal ear canal and drums then early referral is required.

Red flags

• Weight loss.

• Dysphagia.

• Pain.

• Hoarseness or other voice changes which are persistent or worsening.

• Otalgia.

• Unilateral symptoms.

• Risk factors for malignant cause - smoking, alcohol excess, previous radiotherapy or head and neck surgery.

• Regurgitation.

• Systemic symptoms - fever, night sweats.

• Abnormalities on examination - lumps, lymphadenopathy.
  

Differential diagnosis

The differential diagnoses are the causes of true dysphagia. See the separate article Dysphagia for further details.

Investigations¹

• Globus is a diagnosis of exclusion and can only be made once other causes of symptoms have been eliminated.

• A 2000 survey of UK ENT consultants showed that there was no uniform investigation strategy, with 14% saying that they did not investigate, 61% performing rigid endoscopy, 56% requesting a barium swallow, and some asking for other tests such as video fluoroscopy or 24-hour ambulatory pH monitoring. ⁵ 25 years later, there are still no national UK guidelines for the investigation of this symptom.

Globus sensation treatment and management¹

There are no agreed standards for the management of globus sensation.

• Empirical therapy with a proton pump inhibitor may be started if there is suspicion of gastro-oesophageal reflux disease and if history taking, neck examination and nasolaryngoscopy have not revealed any red flag symptoms or abnormal findings. If symptoms persist then further investigation may be needed (as under 'Investigations', above).

• Referral to a speech and language therapist may be helpful. They can suggest neck, shoulder and voice exercises as well as relaxation techniques that may help to relieve symptoms.

• Cognitive behavioural therapy and antidepressants may be helpful for some people with concomitant psychiatric disorders.

• Vocal hygiene advice may be useful - this includes to avoid cigarette smoke, alcohol and caffeine, and to avoid the urge to dry swallow or repeatedly try to clear the throat. Comparing globus with an abnormal sensation such as an itch can be useful.

Prognosis