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 pseudoneurological symptoms relating to voluntary sensory or motor function.²

It is important to emphasise that most patients with such symptoms are likely to have a demonstrable physical cause for their symptoms.³ The diagnosis of globus hystericus cannot not be made reliably without thorough assessment and investigation.

Epidemiology

Epidemiological data are 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 comorbidity in female patients but not in males.⁴

Presentation

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.⁵

Differential diagnosis

• Cricopharyngeal web.
• Symptomatic diffuse oesophageal spasm⁶ (unco-ordinated spasm of the oesophageal muscles).
• Gastro-oesophageal reflux disease.
• Laryngo-pharyngeal reflux disease.⁷
• Skeletal muscle 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.

Investigations

• CXR - 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.⁹ 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.¹⁰ However, another study of 1,145 barium swallow reports of patients presenting with globus failed to identify any such cases.¹¹

If the history reveals psychosocial factors and endoscopic examination and/or barium swallow is normal, a diagnosis of globus hystericus is probable and further investigation may be unnecessary.⁹

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

• Oesophageal manometry - this may be useful in identifying the subsection of globus patients who suffer from upper oesophageal sphincter hypersensitivity.¹²
• Videofluorography - this is useful where structural pathology of the oesophagus is suspected.³ Pharyngeal dysfunction is detected in a substantial proportion of patients presenting with globus.¹³

Associated diseases

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

Management

• 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.³
• The most common 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.⁷ This could either be to a gastroenterologist or an ear, nose and throat (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.⁶
• Psychological treatment for globus hystericus is as for other conversion or somatisation disorders. Psychotherapy, family therapy and cognitive behavioural therapy have all had some benefit.¹⁵
• Antidepressants are sometimes helpful, particularly if there is a family history of depression. Electroconvulsive therapy (ECT) has also proved beneficial in some patients.¹⁶

Complications

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

Prognosis

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 the 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

Document references

1. Owen W; ABC of the upper gastrointestinal tract. Dysphagia. BMJ. 2001 Oct 13;323(7317):850-3.
2. Krem MM; Motor conversion disorders reviewed from a neuropsychiatric perspective. J Clin Psychiatry. 2004 Jun;65(6):783-90. [abstract]
3. Leelamanit V, Geater A, Sinkitjaroenchai W; A study of 111 cases of globus hystericus. J Med Assoc Thai. 1996 Jul;79(7):460-7. [abstract]
4. Deary IJ, Wilson JA, Mitchell L, et al; Covert psychiatric disturbance in patients with globus pharyngis. Br J Med Psychol. 1989 Dec;62 ( Pt 4):381-9. [abstract]
5. Merck Manual Online; Globus sensation, 2003
6. Thompson ABR; Esophageal Spasm, eMedicine, Aug 2009
7. Remacle M, Lawson G; Diagnosis and management of laryngopharyngeal reflux disease. Curr Opin Otolaryngol Head Neck Surg. 2006 Jun;14(3):143-9. [abstract]
8. Lorenz R, Jorysz G, Clasen M; The globus syndrome: value of flexible endoscopy of the upper gastrointestinal tract. J Laryngol Otol. 1993 Jun;107(6):535-7. [abstract]
9. Harar RP, Kumar S, Saeed MA, et al; Management of globus pharyngeus: review of 699 cases. J Laryngol Otol. 2004 Jul;118(7):522-7. [abstract]
10. Tsikoudas A, Ghuman N, Riad MA; Globus sensation as early presentation of hypopharyngeal cancer. Clin Otolaryngol. 2007 Dec;32(6):452-6. [abstract]
11. Alaani A, Vengala S, Johnston MN; The role of barium swallow in the management of the globus pharyngeus. Eur Arch Otorhinolaryngol. 2007 Sep;264(9):1095-7. Epub 2007 Apr 24. [abstract]
12. Corso MJ, Pursnani KG, Mohiuddin MA, et al; Globus sensation is associated with hypertensive upper esophageal sphincter but not with gastroesophageal reflux. Dig Dis Sci. 1998 Jul;43(7):1513-7. [abstract]
13. Finkenbine R, Miele VJ; Globus hystericus: a brief review. Gen Hosp Psychiatry. 2004 Jan-Feb;26(1):78-82. [abstract]
14. Anandasabapathy S, Jaffin BW; Multichannel intraluminal impedance in the evaluation of patients with persistent globus on proton pump inhibitor therapy. Ann Otol Rhinol Laryngol. 2006 Aug;115(8):563-70. [abstract]
15. Yates WR; Somatoform Disorders, eMedicine, Jul 2010
16. Cybulska EM; Globus hystericus--a somatic symptom of depression? The role of electroconvulsive therapy and antidepressants. Psychosom Med. 1997 Jan-Feb;59(1):67-9. [abstract]
17. Ward P; Complications of Gastroesophageal Reflux. West J Med. 1988 July; 149(1): 58-65
18. Timon C, O'Dwyer T, Cagney D, et al; Globus pharyngeus: long-term follow-up and prognostic factors. Ann Otol Rhinol Laryngol. 1991 May;100(5 Pt 1):351-4. [abstract]

Acknowledgements