Globus Pharyngis
Article
By Mr J McGlashan FRCS
Definition
Globus - Latin for ball - describes the sensation of something in the throat. Globus pharyngis - ball in the throat - is the name given to the condition when this is the major symptom and no other serious abnormality is found. The terms are however often used loosely and interchangeably.
Incidence - Age
The true incidence is not known but many people have experienced this feeling most usually associated with strong emotions - 'it brought a lump to my throat'. In one study it was the reason for referral to an Ear, Nose and Throat Department in 4% of cases. It can affect people of all ages although it is uncommon in children. In another study it was shown to affect more women than men less than 50 years of age but the sexes equally over this age.
Relevant Applied Anatomy And Physiology
The exact mechanism for globus is not known and may be different in different individuals. The brain perceives this sensation of a lump or something in the throat but often medical examination and tests do not reveal any physical abnormality. Some cases are probably due to increase tension in the muscles of the throat, others due to irritation or swelling of the lining of the throat and others from altered perception or awareness of the throat.
Causes
The exact cause of globus is not known and some of the medical studies in the literature have given confusing and contradictory results. Some cases are made worse or associated with:
Acid Reflux
Larygopharrngeal reflux (LPR or 'silent reflux') is a relatively newly recognized condition in which the stomach contents reflux up to the level of the larynx (voice box). It differs from classical gastroesophageal reflux in that it is not always associated with heartburn but can be associated with chronic (lasting a long time) throat clearing, phlegm in the throat and changes in the voice.
Cervical Spondylitis - Arthritis in the Neck
Cervical spondylitis is a very common condition and not all sufferers get globus. However some probably suffer from increased muscle tension in the neck and around the larynx causing globus.
Goitre - Enlargement of the Thyroid Gland
General enlargement, nodules and inflammation in the thyroid gland are quite common and can occasionally cause a globus sensation. More often it can also be a coincidental finding.
Certain Medications
Patients taking diuretics ('water tablets' usually prescribed for high blood pressure), ACE inhibitors (a specific type of drug taken for high blood pressure and heart failure) and antimuscarinics (a group of drugs used in a diverse of variety of conditions such as irritable bowel, urinary problems and psychiatric conditions) can have irritating or drying effects on the throat and occasionally cause a globus sensation.
Anxiety and Depression
Patients are naturally worried that there is a serious cause for the globus sensation frequently fearing they may have cancer. Fortunately throat cancer is extremely uncommon particularly in people who do not smoke or drink excessively and most cases are obvious from other associated symptoms or on examination.
There is a higher incidence of anxiety disorders (including panic attacks) and depression in patients with globus. Globus may be experienced by individuals at times of emotional stress particularly when they feel unable to express their feelings or when it would be inappropriate to show their feelings.
Symptoms And Signs
The predominant symptom is of course a sensation of something in the throat. Typically this disappears momentarily on swallowing and may worsen in the evenings. Often it may appear difficult to swallow saliva and pills although it is possible to eat a normal diet and there is no weight loss. Patients frequently clear their throat and feel the need to swallow. It can be associated with hoarseness or a change in the voice.
Typically there are no abnormal findings on examination of the throat although there may be signs of laryngeal swelling associated with reflux. The patient may well look healthy, albeit anxious.
Tests
Often no tests other than a detailed inspection of the throat and larynx are necessary. If one of the major symptoms is difficulty swallowing then a Barium Swallow X-ray may be requested. A special test which involves monitoring the amount of acid that refluxes up into the oesophagus ('24 Hour pH monitoring') can be helpful in deciding whether acid reflux is a major cause of the globus.
Occasionally in patients at risk of cancer, who do not have straightforward symptoms or whose symptoms seem to be getting worse, they may be advised to come into the hospital for a more detailed examination of their throat under a general anaesthetic.
Treatment
Treatment consists of one or more of the following:
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Reassurance
Many patients are worried that they have cancer or some serious disease and once reassured their anxiety and associated symptoms then settle.
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Vocal Hygiene Advice
Sometimes simple advice such as changing life style, diet, stopping throat clearing, drinking more water and less drinks containing caffeine (coffee, tea, cola) can be helpful. This can be given in more detail Voice Therapists.
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Voice Therapy
If there is evidence of hoarseness due to an imbalance of the laryngeal muscles ('Functional dysphonia') then exercises and advice from a Voice Therapist can not only help the voice problem but also help relieve the globus sensation. A Voice therapist may also be able to give advice with general relaxation and anxiety management, posture and breathing exercises in conjunction with physiotherapists and counsellors were necessary.
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Medication
If certain medications are thought to be a possible cause then the patient may be recommended to change them (under supervision of the hospital specialist or general practitioner). Alternatively a trial of anti-reflux medication may be advised. This may have to be given in higher than normal doses for at least 2 months.
Outcome
Most patients respond to one or more of the above treatments. Persistent symptoms may need to be investigated further, often with an examination under an anaesthetic although this frequently does not reveal any abnormality.
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References:
Mr. J McGlashan FRCS
www.heros.org.uk
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