Globus Hystericus

This is defined as a subjective feeling of a lump in the back of the throat without true dysphagia.¹ It is sometimes called globus sensation or globus pharyngis. It is thought to be a type of conversion or somatisation disorder. Conversion disorder itself is defined as a somatoform disorder which presents as pseudoneurologic symptoms relating to voluntary sensory or motor function.²

Epidemiological data is sparse and the information that is available is not particularly recent. However, globus sensation is thought to be a common symptom.¹ One study based on a validated psychological research questionnaire concluded that there was a significant psychiatric co-morbidity in female patients but not in males.³

The patient complains of a lump in the throat not associated with eating. The sensation may in fact be relieved by eating or drinking. There is no actual pain or discomfort. The symptom may be triggered by or aggravated by stress.⁴

• Cricopharyngeal web
• Symptomatic diffuse oesophageal spasm⁵ (uncoordinated spasm of the oesophageal muscles)
• Gastro-oesophageal reflux disease
• Laryngo-pharyngeal reflux disease⁶
• Skeletal muscles disorders (e.g. myasthenia gravis, polymyositis, myotonic dystrophy)
• Neurological disease - stroke, cranial nerve palsy, Parkinson's disease
• Benign or malignant tumours of the neck and mediastinum causing oesophageal compression
• Causes of true dysphagia

If the history reveals psychosocial factors and endoscopic examination is negative, a diagnosis of globus hystericus is probable and further investigation may be unnecessary.⁷

In cases of diagnostic difficulty, persisting symptoms or treatment failure, however, the following may be helpful:

• Chest X-ray - to exclude mediastinal tumours.
• Endoscopy - to exclude reflux oesophagitis and other oesophageal pathology.⁸
• Barium swallow - the role of this investigation is controversial. It has been used to exclude oesophageal or pharyngeal cancer in patients with atypical symptoms but normal endoscopy.⁷ One study found that 9% of patients presenting with globus sensation as the only symptom were found to have hypopharyngeal carcinoma; in these patients there was a 78% pick-up rate in the barium swallow.⁹ However, another study of 1,145 barium swallow reports of patients presenting with globus failed to identify any such cases.¹⁰
• Oesophageal manometry - this may be useful in identifying that subsection of globus patients who suffer from upper oesophageal sphincter hypersensitivity.¹¹
• Videofluorography - this is useful where structural pathology of the oesophagus is suspected.¹² Pharyngeal dysfunction is detected in a substantial proportion of patients presenting with globus.¹³

Gastro-oesophageal reflux, laryngo-pharyngeal reflux, upper oesophageal sphincter hypersensitivity, anxiety, depression.

• It is important to identify secondary causes and treat them adequately. Many cases initially labelled 'globus' have subsequently been found to have treatable pathology. One study of 111 patients found that 73.9% of the sample had demonstrable functional abnormality on videofluorography.¹²
• The commonest associated factor is oesophageal reflux and empirical treatment with a proton pump inhibitor is worth trying. However, a recent study which measured impedance in the oesophageal lumen over a 24 hour period found that 64.7% of patients found to have reflux in fact had non-acidic reflux of the proximal oesophageal contents rather than true acid reflux.¹⁴ If the patient fails to respond, referral for further investigation is required to rule out underlying causes.⁶ This could either be to a gastroenterologist or an ENT surgeon depending on clinical suspicion.
• Globus associated with oesophageal spasm may respond to calcium channel blockers (e.g. diltiazem) or nitrates (e.g. isosorbide mononitrate).These drugs are usually initiated by specialists after confirmatory investigations and are not licensed for this indication in the UK.⁵
• Psychological treatment for globus hystericus is as for other conversion or somatisation disorders. Psychotherapy, family therapy and cognitive behaviour therapy have all had some benefit.¹⁵
• Antidepressants are sometimes helpful, particularly if there is a family history of depression. ECT has also proved beneficial in some patients.¹⁶

There are no complications of psychogenic globus per se, other than those of the underlying psychopathology. Unrecognised, untreated and persistent laryngo-oesophageal or gastro-oesophageal reflux can however lead to cancer of the larynx and cancer of the oesophagus.¹⁷

This is generally good. One series of 80 patients found that 25% had no symptoms at an average follow up assessment at 27 months (range 21 to 42 months), whilst a further 35% had considerable improvement in symptoms. Factors influencing prognosis included duration of symptoms at time of diagnosis, gender and associated throat symptoms. Patients most likely to have a good prognosis were males who had a history of less than three months on presentation and no associated throat symptoms.¹⁸