An insight into globus pharyngeus: A diagnostic dilemma

Introduction

Globus pharyngeus is a common disorder encountered in patients in Otorhinolaryngology out-patient department. Patients often express this as a feeling of foreign body stuck in throat or choking sensation in throat. It accounts for 5% of fresh referrals to the ENT specialist.^[1], ^[2]  Historically globus was primarily thought to have a psychological association and was termed as “globus hystericus”.^[1], ^[3] However, it was renamed more accurately to “globus pharyngeus” in 1968 by Malcolmson.^[1], ^[4] Globus Pharyngeus is  defined as (i) a persistent or intermittent sensation of a lump or foreign body in the throat for at least 12 weeks, (ii) occurrence of the sensation between meals, (iii) absence of dysphagia and odynophagia, (iv) absence of pathological gastroesophageal reflux (GERD), achalasia, or other motility disorder with a recognized pathological basis (e.g., scleroderma of the oesophagus). ^[2], ^[5] 

Etiology

Globus pharyngeus can be attributed to multiple etiological factors as listed below (can be remembered as acronym GLOBUS Pharyngeus).

Gastric Mucosal patches in cervical oesophagus have been associated with globus pharyngeus, these are deemed to be congenital in nature and have been referred to as cervical heterotopic gastric mucosa (CHGM).^[2], ^[6], ^[7], ^[8] The acid production from this heterotopic gastric mucosa leads to symptoms similar to gastroesophageal reflux disease.

Laryngopharyngeal reflux secondary to gastroesophageal reflux disease leads to direct irritation and inflammation of the mucosa due to retrograde flow of gastric contents.^[8] 

Oesophageal motility disorder- This is another potential cause for globus pharyngeus.^[8] 

Base of tongue hypertrophy- Hypertrophy of the follicles of the base of tongue and lingual tonsils may also contribute to symptoms when these follicles touch the posterior pharyngeal wall.^[8] 

Upper oesophageal sphincter function- Hypertonicity of the upper oesophagus may also be attributed to globus, however various studies have revealed contradictory results.^[8], ^[9]  

Stress and psychological disorders have been seen to be associated with globus sensation. Historically named as “Globus hystericus”, studies have revealed higher levels of anxiety, somatic concerns in patients presenting as globus. ^[3], ^[8], ^[9]  

Pharyngeal inflammation and irritation secondary to chronic pharyngitis, tonsillitis, post nasal discharge due to chronic sinusitis may lead to globus sensation.^[8] 

Other factors that may contribute include retroverted epiglottis, impalpable thyroid nodules and cervical osteophytes.^[8] 

Diagnosis and Management

Globus pharyngeus has multifactorial etiology and hence there is no single treatment modality. Reassurance is the mainstay of the treatment. If history and examination suggest associated gastroesophageal reflux disease then a course of proton pump inhibitors (PPI) along with dietary and lifestyle modifications can be started. If the patient responds well to treatment, then consider weaning off the patient from PPI.^[8] Other treatment modalities include speech therapy and relaxation exercises, cognitive behavioral therapy. Laser ablation of CHGM by argon plasma coagulation has also reported improvement in symptoms of globus. ^[6], ^[7], ^[8]

Conclusion

The diagnosis is based on complete history, detailed examination however investigations should be performed to rule out malignancy of the upper aerodigestive tract and to diagnose associated disorders. Diagnostic endoscopy should be performed to rule laryngopharyngeal lesions. Risk factors like smoking, elderly age group, symptoms with acute onset like odynophagia, dysphagia warrant further investigations. Globus pharyngeus is a clinical diagnosis, clinician must avoid over- investigating the patient unless warranted.

Source of Funding

None.

Conflict of Interest

None.