Globus Hystericus

This is defined as a subjective feeling of a lump in the back of the throat without true dysphagia¹. 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 function².

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 males³.

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 stress⁴.

• Cricopharyngeal web
• Symptomatic diffuse oeosophageal spasm⁵ (uncoordinated spasm of the oesophageal muscles)
• Gastro-oesophageal reflux disease
• Laryngo-pharyngeal reflux disease⁶
• Skeletal muscles disorders (e.g. myasthenia gravis, polymyositis, myotonia dystrophica)
• 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 examination is negative, a diagnosis of globus hystericus is probable and further investigation may be unnecessary⁷.
In cases of diagnostic difficulty, persisting symptoms or treatment failure, however, the following may be contributory:

• Chest X-ray - to exclude mediastinal tumours
• Endoscopy - to exclude reflux oesophagitis and other oesophageal pathology⁸
• Barium swallow - sometimes useful if symptoms are atypical but endoscopy is normal⁷
• Oesophageal Manometry - this may be useful in identifying that subsection of globus patients who suffer from upper oesophageal sphincter hypersensitivity⁹
• Videofluorography - this is useful where structural pathology of the oesophagus is suspected¹⁰.

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 videofluorography¹⁰.
• The commonest associated factor is oesophageal reflux and empirical treatment with a proton pump inhibitor is worth trying
• If the patient fails to respond, referral for further investigation is required⁶
• 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 UK⁵.
• Psychological treatment for globus hystericus is as for other conversion or somatisation disorders. Psychotherapy, family therapy and cognitive behaviour therapy have all had some benefit¹¹.
• Antidepressants are sometimes helpful, particularly if there is a family history of depression. ECT has also proved beneficial in some patients¹².

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 oesophagus¹³.

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 symptoms¹⁴.