Globus Pharyngeus: Epidemiology, Aetiology

Introduction

Globus pharyngeus is a condition that causes a feeling of something being struck or a lump or tightness in the throat. It is a well-defined clinical symptom that is persistent, difficult to treat and tends to recur. It can be a silent manifestation of atypical silent gastroesophageal reflux disease. Globus pharyngeus is a functional esophageal disorder characterized by a sensation of a lump, retained food bolus, or tightness in the throat that is not due to an underlying structural lesion, gastroesophageal reflux disease, mucosal abnormality, or esophageal motility disorder.

Epidemiology of Globus Pharyngeus 

Prevalence of Globus Pharyngeus is not so common and accounts for 4% of otolaryngological referrals. Nearly 45% of the general population experiences mild intermittent symptoms resembling globus pharyngeus at least once in their lifetime. The peak incidence of the condition often presents in the middle age.

Aetiology of Globus Pharyngeus

•  Psychogenic problems are often thought to cause globus pharyngeus. There is no actual disease or any pathology involved. 
• Strap muscle spasm
• A lingual tonsil is present at the midline on the base of the tongue and hypertrophied lingual tonsils present with a feeling of a lump or blockage, or tightness of the throat. 
• Anterior cervical osteophytes
• As age advances or due to spondylosis, anterior protrusion of these cervical vertebrae causes indentations in the posterior pharyngeal wall, which presents with a symptom of blockage in the throat.

• Sometimes dental alignment, like overclosure of bite, causes globus pharyngeus.
• Granular pharyngitis
• Tonsillitis: Tonsillar hypertrophy is the least possible etiological factor of Globus pharyngeus.
• Thyroid nodules.

Causes attributing To Globus Pharyngeus

1. Gastrointestinal reflux Disease (GERD)
   • Gastrointestinal reflux is a highly anticipated cause of the Globus sensation. 
   • The contact of refluxed acid and pepsin with esophageal and tracheal mucosa triggers vagal refluxes, which in turn causes spasms.
   • Direct inflammation of the upper esophageal region with or without frank esophageal reflux.
   • Distal or proximal esophageal exposure results in reflex cough and throat clearing. 
2. Inferior Constrictor Strain Swallows
   • Increased awareness of contact between epiglottis and lingual tonsils provokes a vicious cycle of dry saliva swallowing.
   • Increased frequency of swallowing results in a reduction in inter-swallowing interval.
   • This repeated dry saliva swallow cycle leads to aerophagy and failure of the upper esophageal sphincter, which results in tightness and creates a feeling of a lump in the throat.

3. Psychogenic or Non-Organic cause

• It is the most common causative factor for Globus pharyngeus. 
• Certain psychological disturbances like depression, anxiety, and stress can be present in patients with Globus pharyngeus. 
• Depressed or anxious patients with or without panic attacks 
• Death of a family member due to pharyngeal or laryngeal cancer can give rise to depression and fear, as a result of which patients start complaining of a foreign body in the throat. 
• Neuroticism, introversion, and excessive somatic concern 

4. Other Causes 

• It is important to rule out whether it is due to cancer or not. 
• Investigation like Fiberoptic Laryngopharyngoscopy helps to visualize the larynx, epiglottis, cricoid, pyriform fossa, and posterior pharyngeal wall. 
• Patients with psychological causes can objectively see the video, which helps them to come out of it.

Symptoms Of Globus Pharyngeus

• Globus may be described variably as a piece of hair, skin, a blob of catarrh, or a choking sensation, as well as a classic ball, lump, or foreign body in the throat.
• True dysphagia and odynophagia are usually absent.
• The sensation mostly occurs in between meals.
• There is no loss of appetite or weight loss. 

Examination and Diagnosis Of Globus Pharyngeus

• Complete otorhinolaryngological examination should be conducted first.
• Fiberoptic laryngopharyngoscopy is mandatory to evaluate the nasopharynx, oropharynx, hypopharynx, and oral cavity. No obvious organic pathology should be there.
• Palpation of the neck is necessary to rule out a lymph node, thyroid nodule, or thyroid cyst. Sometimes, it helps to reveal unknown primary and secondary lymph nodes in the neck.
• Video laryngoscopy helps to rule out any physical laryngeal and organic pathology. 

Management Of Globus Pharyngeus

The patient needs to be explained and reassured that there is no organic pathology. This can alleviate the symptoms of globus. Counseling potentially helps to get rid of the symptoms in depressed and anxious patients.  Anti-reflux therapy with a High dose of Proton pump inhibitors plays a good role in the treatment of GERD. Tricyclic Anti-depressants may be considered in the presence of coexisting diagnosed psychiatric illness.

Relaxation training with meditation and massage helps relieve the spasm. Head and neck exercises, acupuncture, and hypnotherapy can also help manage Globus Phryngeus.

By taking frequent sips of water, you can break the vicious cycle of dry swallowing and avoid the constriction of the upper esophageal sphincter. Avoiding smoking and alcohol can relieve symptoms in many patients.

Protocol for Management Of Globus Pharyngeus

• A detailed history of the symptoms and clinical examination of the neck play vital roles in diagnosing and managing Globus pharyngeus.
• If there is a suspicion of GERD, a high dose of proton pump inhibitor (PPI) has to be started. 
• Titration of PPI dose is advised if there is relief in the symptoms. 
•  Increase the dose of a proton pump inhibitor for partially resolved symptoms.
• If patients are nonresponsive to PPI therapy, definitive evaluation, such as barium swallow, Upper GI endoscopy, pH evaluation, and esophageal manometry, is performed.
• Treat if any pathology is present.
• If there is a high-risk patient or there is any abnormal laryngeal finding – Evaluate and treat accordingly.

Frequently Asked Questions

Question: Which age group shows the peak incidence of Globus sensation?

Answer: The peak incidence of the Globus Phryngeus is in middle age.

Question: Spasm of which muscle makes the feeling of a struck throat?

Answer: Strap muscle spasm

Question: How do I get rid of Globus in my throat?

Answer: You need to understand and be reassured that there is no organic pathology. This can alleviate the symptoms of globus. Counseling and psychotherapy help to get rid of the symptoms as well.