Globus Sensation

Globus sensation is a persistent or intermittent, non-painful sensation of a lump, tightness or foreign body in the throat, felt in the midline at or above the sternal notch, which is often relieved by eating or drinking (swallowing food and liquid) and is worse with swallowing saliva or empty swallowing. It occurs in the absence of dysphagia (difficulty in the passage of food), odynophagia (painful swallowing), gastro oesophageal reflux disease causing the sensation, and a structural, motility or inflammatory cause.

• It is very common: about 46% of healthy people experience it at some time, and 4 to 8% of the population report it in a given period. It accounts for about 4% of ENT referrals. Women and those aged 30 to 60 years are slightly more affected, with peak presentation in the fifth decade.
• Mechanisms (multifactorial):
  • Laryngopharyngeal and gastro oesophageal reflux (irritation of the upper aerodigestive tract and the cricopharyngeal region).
  • Upper oesophageal sphincter hypertonia or abnormal pressure, and cricopharyngeal muscle tension.
  • Pharyngeal and laryngeal muscle tension (muscle tension dysphonia), with hypervigilance to throat sensations.
  • Postnasal drip, chronic rhinosinusitis and pharyngitis, with mucus and frequent throat clearing.
  • Psychological factors: anxiety, stress, panic, depression, somatisation and other functional symptoms. Globus often worsens during periods of stress.
  • Structural: thyroid enlargement or nodules, cervical osteophytes, prominent hyoid or styloid, cricopharyngeal bar, pharyngeal pouch (Zenker diverticulum), lingual tonsil hypertrophy, tonsil stones, epiglottic cysts, vallecular cysts, and laryngeal webs, with a small proportion of true structural causes (below 5 to 10%).
  • Malignancy (hypopharyngeal, laryngeal, oesophageal, and thyroid cancers) is a rare cause, but must be excluded when red flags are present.
• Risk factors: reflux disease, anxiety and depression, chronic throat clearing, and voice overuse. Many patients have more than one contributor.
• The condition is benign, and often settles in months, but 20 to 40% have symptoms for longer than a year. It does not predispose to cancer.

• A sensation of a lump, tightness, fullness, choking, a "ball" or a hair in the throat, located in the midline, which does not interfere with swallowing of food and drink, and often feels better while eating. It may be worse when swallowing saliva, during stress, at the end of the day, or when the patient is concentrating on the throat. There is no weight loss, and no true food sticking.
• Associated symptoms: frequent throat clearing, a sensation of mucus or postnasal drip, hoarseness, cough, heartburn and regurgitation (reflux), throat tightness with stress, and neck tension.
• Examination: normal oral and neck examination, with a careful assessment of the thyroid, cervical lymph nodes, and neck. Tenderness over the hyoid or thyroid cartilage may be present, and the posterior pharyngeal wall may show lymphoid hyperplasia.
• Differential diagnosis: dysphagia from oropharyngeal and oesophageal disease (achalasia, stricture, eosinophilic oesophagitis, pharyngeal pouch), reflux laryngitis, thyroid disease, malignancy of the head and neck, retropharyngeal and neck masses, cervical spine disease, muscle tension dysphonia, anxiety disorder, tonsillar disease, and, rarely, angina or an aortic aneurysm.
• Red flags: true dysphagia (food sticking), odynophagia, unintentional weight loss, persistent hoarseness (more than 3 weeks), a neck lump, unilateral throat pain or referred otalgia, haemoptysis, haematemesis, a history of smoking or heavy alcohol use with age over 50 years, persistent unilateral tonsillar enlargement, a family history of head and neck cancer, stridor, recurrent aspiration, a history of head and neck radiation, and neurological features.
• Complications: anxiety about cancer (cancerophobia), sleep disturbance, increased throat clearing and voice problems, reduced quality of life, and repeated health care visits.

• Careful history to distinguish globus (a sensation with no swallowing difficulty) from dysphagia, and examination of the mouth, oropharynx, neck and thyroid.
• Flexible nasopharyngolaryngoscopy (transnasal fibreoptic laryngoscopy) by an ENT specialist for all patients with persistent globus beyond 3 to 4 weeks, or with any red flag, to look at the pharynx, base of tongue, valleculae, larynx and hypopharynx. The finding of erythema and oedema of the arytenoids (suggesting reflux) is non-specific. A normal examination is common, and in itself is reassuring.
• Blood tests: thyroid function tests when thyroid enlargement or symptoms exist, full blood count, and ferritin (a low level can contribute to pharyngeal symptoms and is associated with Plummer-Vinson syndrome in dysphagia).
• Imaging, as directed by the findings: thyroid and neck ultrasound for a goitre, nodule or mass, a barium swallow for dysphagia (to show a pharyngeal pouch, cricopharyngeal bar, stricture, or hiatus hernia), cervical spine X-ray for suspected osteophytes, and CT or MRI of the neck for a mass or suspected malignancy.
• Upper gastrointestinal endoscopy (with biopsies) for dysphagia, odynophagia, alarm features, or persistent symptoms with suspected reflux or eosinophilic oesophagitis. Oesophageal manometry and pH monitoring for refractory symptoms, and when dysphagia or motility disorder is suspected.
• Assess for anxiety, depression and somatic symptom disorder, and the patient's concerns (often fear of cancer).

• Reassurance after a careful history and examination (including laryngoscopy when indicated) is the most important part of treatment, and it resolves or improves symptoms in the majority. Explain the cause, the harmless nature, and the lack of association with cancer after appropriate evaluation.
• Reduce throat irritants and habits: avoid frequent throat clearing and coughing (replace with a sip of water or a silent swallow), stop smoking, limit alcohol and caffeine, keep well hydrated, and avoid very hot or irritant foods. Steam inhalation and honey in warm water may soothe the throat.
• Treat associated reflux when features of gastro oesophageal or laryngopharyngeal reflux are present: omeprazole 20 to 40 mg orally once or twice daily (30 to 60 minutes before meals) for 8 to 12 weeks, an alginate (sodium alginate and potassium bicarbonate 10 to 20 mL after meals and at bedtime), dietary measures (avoiding late meals, fatty and spicy food, alcohol, caffeine), weight loss, and raising the head of the bed by 10 to 15 cm. Stop the proton pump inhibitor if there is no improvement at 8 to 12 weeks, as the evidence for long term benefit in globus without reflux is weak.
• Treat nasal and sinus disease: fluticasone propionate nasal spray 50 micrograms per spray, 2 sprays into each nostril once daily, saline irrigation, and a second generation antihistamine (cetirizine 10 mg once daily) for allergic rhinitis.
• Speech and language therapy for muscle tension and voice problems (relaxation of the neck and throat, reducing laryngeal tension, breathing exercises, and vocal hygiene, 3 to 6 sessions), and physiotherapy for neck and shoulder tension (manual therapy, posture, and stretching).
• Psychological treatment: cognitive behavioural therapy, relaxation, mindfulness, and stress management, particularly for patients with anxiety or persistent symptoms. A short course of a low dose of neuromodulator for refractory symptoms: amitriptyline 10 mg orally at night, increased by 10 mg every 1 to 2 weeks to 25 to 50 mg, or sertraline 25 to 50 mg once daily (increase to 100 mg), or citalopram 10 to 20 mg daily, for 8 to 12 weeks, in a patient with anxiety or depression.
• Structural causes: treat thyroid disease according to function and size, with surgery for compressive goitre or suspicious nodules. Treat lingual tonsil hypertrophy, tonsil stones and cysts as appropriate, and refer a pharyngeal pouch for surgical management (endoscopic stapling or open diverticulectomy with cricopharyngeal myotomy).
• Cricopharyngeal hypertonia and refractory globus (specialist care): botulinum toxin injection into the cricopharyngeus muscle (10 to 30 units in total, under electromyographic or endoscopic guidance), or dilatation, with a benefit in about 50 to 70% of selected patients, and a risk of transient dysphagia and aspiration.
• Cancer or suspicious lesions: urgent specialist assessment, biopsy and staging.
• Special groups:
  • Pregnancy: use reassurance, hydration, antacids (calcium carbonate), alginate, and omeprazole 20 mg daily only if needed. Avoid neuromodulators unless essential.
  • Children and adolescents: globus is rare. Evaluate for anxiety, throat disease and swallowing problems, and treat with reassurance and speech therapy.
  • Elderly: have a lower threshold for investigation (laryngoscopy, imaging, endoscopy) because of the greater risk of malignancy, pharyngeal pouch and swallowing disorders. Use lower doses of neuromodulators.
  • Smokers and heavy drinkers: strongly advise cessation, and do laryngoscopy early.
  • Renal and hepatic impairment: use lower doses of neuromodulators and avoid long term proton pump inhibitor without benefit.
• Follow up: review at 4 to 8 weeks after starting treatment, and sooner if red flags develop. Refer to ENT for persistent symptoms beyond 3 to 4 weeks, hoarseness lasting over 3 weeks, or any alarm feature. Refer to gastroenterology for dysphagia, suspected oesophageal disease, or refractory reflux symptoms, and to a speech and language therapist or psychologist for muscle tension and anxiety.