Globus Presents Diagnostic Challenge for Otolaryngologists

Most otolaryngologists have come across cases of globus pharyngeus, or the persistent sensation of having a lump, obstruction, or too much mucus in the throat without clinical evidence of such. Globus can come and go and is usually felt in the front of the neck, although the sensation can move. It does not interfere with eating and drinking, and patients commonly feel no pain.

Although globus is thought to be quite common, there are not enough recent, reliable studies available to show specific numbers of patients who are affected. To those patients who have globus, however, the sensation can be a real cause of anxiety. The challenge for otolaryngologists is to find the specific source of the globus while quelling any patient concerns.

A Multitude of Causes

The etiology of globus isn’t fully known, but there are many conditions otolaryngologists consider responsible.

Inflammation is a frequent culprit in globus, and the most commonly cited cause for the sensation is reflux. “Inflammation of one or more parts of the throat is one of the main causes of globus,” said Michael Pitman, MD, director of the Voice and Swallowing Institute at the New York Eye and Ear Infirmary of Mount Sinai in New York City. “Inflammation caused by laryngopharyngeal reflux is by far the most common type, although it can also come from issues such as rhinitis or allergies.”

Adam Rubin, MD, co-director of the Lakeshore Professional Voice Center, part of the Lakeshore Ear, Nose and Throat Center in St. Clair Shores, Mich., believes that neuralgia is a close second in etiology.

Dr. Rubin recently served as senior author for a study on the use of gabapentin in patients with globus (Ann Otol Rhinol Laryngol. 2013;122:492-495). He and his colleagues looked at 87 patients who presented with globus pharyngeus between 2006 to 2011 at Lakeshore Ear, Nose and Throat Center and were given a trial of proton pump inhibitor therapy for at least two months and/or a trial of gabapentin for at least two weeks, with at least one follow-up visit.

After treatment, 77% of all patients showed improvement, 67% showed a complete or partial response to aggressive reflux management, and 66% of patients who had a trial of gabapentin reported improvement. In addition, eight of 14 patients who did not improve with aggressive reflux management improved with gabapentin. Dr. Rubin believes that these results point to neuralgia being a more common cause of globus than previously thought. “I believe that many neurogenic cases go undiagnosed,” he said.

According to Drs. Pitman and Rubin, the list of other possible causes could include:

• Esophageal problems;
• Thyroid issues, such as thyroiditis and goiter;
• Muscle strain and muscle tension dysphonia from overuse of voice or tightness of muscles from speaking;
• Cervical spine osteophytes;
• Lingual tonsil hypertrophy;
• Medications, such as sprays that relax the throat; and
• Isolated cases in which tumors or malignancy cause a globus sensation.

Globus has been referred to as globus hystericus, although the term is out of use today. Although there is no connection to women’s health issues, as the term might suggest, there can be a connection between globus and anxiety. “Anxiety and globus is really a ‘chicken and egg’ scenario,” said Dr. Rubin. “It can be difficult to tell which was first to show up. Also, it is known that anxiety may make a globus sensation worse.”

Globus has been recognized as a symptom of depression and other psychological disorders. In a 2009 study, for example, globus was linked with depression and somatization disorder among a wide range of psychopathology in men (Psychosom Med. 2009;71:1026-1031).

Identifying the Problem

Treatments for globus can vary as widely as its etiology, but investigating the exact cause and ruling out possibly devastating factors are the first steps.

“The goal is to rule out significant pathology, identify the etiology of the symptoms, and then decide whether or not it’s worth treating,” said Dr. Pitman. “Reassuring the patient that the sensation is real and ruling out a dangerous disorder is often enough. If a patient wants to try to alleviate the sensation, then an otolaryngologist might try a few things. Sometimes it’s difficult to identify the specific etiology, so you have to use your best presumption based on the general findings of the history and physical exam. It is important to then systematically treat the possibilities to help not only alleviate the symptoms but also to identify the diagnosis.”

One of the most useful diagnostic tools is transnasal esophagoscope. “Because the possibility that an esophageal disorder or tumor can cause globus, this tool is being used to evaluate the esophagus by more otolaryngologists to make sure that they aren’t missing something,” said Dr. Pitman.

“Some physicians order CT scans or even proceed to the operating room for endoscopy under general anesthesia to rule out a more ominous etiology,” added Dr. Rubin. “If an otolaryngologist suspects upper esophageal sphincter spasm or esophageal dysmotility, a barium swallow and high-resolution manometry can help confirm it. Also, pH probe testing and impedance testing can help search for reflux. However, I personally feel that empiric treatment with reflux medications and/or gabapentin, or other medication used to treat neuralgia, can be diagnostic as well as therapeutic,” said Dr. Rubin. “The majority of cases will get better with these treatments, and additional testing can be avoided.”

“I tend to think radiologic imaging is unnecessary in most cases unless the patient is at a higher risk for malignancy—for example, [if] they smoke or have other ominous symptoms, or if there’s no improvement with empiric treatment,” said Dr. Rubin. “However, the level of concern is marginally higher if the globus is a feeling of a lump rather than a ‘mucous’ sensation, and it can be argued that gabapentin could mask a malignancy, so clinical acumen and follow-up is warranted. But, of course, in-office endoscopy and head and neck examination allow us to evaluate the patient fairly thoroughly.”

Resolving the Issue

Newer cases of globus sensation often resolve themselves, but this is less likely to happen in longer-standing cases. There are key treatments that can help resolve the problem. Because reflux is the most common cause of globus, medications that treat reflux, including proton pump inhibitors, H2 receptor blockers, and

antacids, can help eliminate the mucous sensation that patients often feel. A very strict diet to keep reflux under control, in combination with medication, can also help.

If neuralgia is suspected, protein pump inhibitors and gabapentin, commonly used to treat seizures and nerve pain, can improve the condition. Because gabapentin generally works in a few weeks rather than the few months required for reflux medications, using it for treatment can provide diagnostic insight as well. “We have a new understanding of vagal motor and sensory neuropathies that occur; they are often treated with medications like amitriptyline HCl,” said Dr. Pitman. “At the moment, it’s unclear if such treatment is viable for “idiopathic” globus, but it’s being investigated.”

Additional empirical remedies must be assessed based on the suspected cause. Voice therapy can often be useful in cases involving muscle strain, for instance, while antidepressants may help resolve the sensation in patients who have globus that is connected to a form of anxiety disorder.

Finding a resolution of symptoms can require a tremendous effort, however, and this may not be important to all patients. “If none of the treatments you try are successful, you may find that some patients decide that, so long as they know they’re healthy overall, it’s all right with them to not treat the globus,” added Dr. Pitman.

Reassuring Patients

The bottom line, according to both Drs. Pitman and Rubin, is to reassure patients who are concerned about what the sensation might mean in terms of their health. “Patients will often come in very worried,” said Dr. Rubin. “Reassure them that it is unlikely the sign of anything terribly serious, and that as a physician, your goals are to rule out anything bad and to try to help improve the system.”

“Once you’re convinced that there isn’t a significant pathology that’s causing the sensation, then reassurance is probably one of the best treatments you can offer your patients,” said Dr. Pitman. “For many, that’s what they’re looking for—the globus doesn’t really bother them, but the anxiety that they might have a serious health problem does.”

Regardless of the treatment path, it’s important to remember that globus itself is a symptom. “So long as you have performed evaluations to the point where you believe that nothing detrimental to the patient’s health is going on, then you can monitor it without treatment,” said Dr. Pitman. “Each patient is different.”

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Amy Eckner is a freelance writer based in Calif.