33 Globus Pharyngeus
Globus pharyngeus is the description of a typical symptom complex, and a diagnosis of exclusion. The symptoms are variably described, but generally are perceived as the sensation of a lump, discomfort, tightness or foreign body in the throat. It is a common reason for ENT clinic referral and the emphasis is primarily on the exclusion of a serious underlying disorder, and secondarily, the identification of underlying contributory factors that can be treated. The priority for most patients is the exclusion of cancer, but it should be remembered globus pharyngeus is very common and throat cancer is very uncommon.
33.1 Clinical Presentation and Assessment in Clinic
Patients can be of any age and of either sex. The complaint is typically of a sensation of a lump in the throat, usually between the sternal notch and thyroid cartilage. The patient might perceive the lump as an irritation, a foreign object stuck in the throat, catarrh stuck in the throat (and maybe as a post-nasal drip), persistent dryness and, or tightness. It is often difficult to define and describe, hence the variety of descriptions. It is usually central but can lateralise.
Initial clinical assessment consists of taking a thorough history, ENT examination and flexible nasopharyngolaryngoscopy.
Table 33.1 summarises the commoner and important possible underlying causes or factors (when there is one that can be identified), and the symptoms and signs that can help to guide the clinician. When an underlying pathology can be identified, then the diagnosis is no longer ‘globus pharyngeus’ rather that of the underlying pathology.
The first priority is the identification of features that might suggest the possibility of cancer. These are described in Table 33.1. A key direct question to ask the patient is what happens to the symptom when eating or drinking. Typically in globus pharyngeus, the symptom will improve or even disappear for a time, and tends to be more noticeable when not swallowing or with a ‘dry’ swallow.
A worsening of symptoms with swallowing should alert the clinician to a physical abnormality, including cancer. Other features that alert the clinician to a possibility of cancer are noted in Table 33.1. Note that the absence of a smoking history should not be taken as a reassuring factor, especially in the current era of human papilloma-virus (HPV)-driven oropharyngeal cancer.
The second priority is to identify any other specific underlying cause. This includes laryngopharyngeal reflux (LPR). All of the typical LPR symptoms noted in Table 33.1 can be present when there is no reflux at all, as in cases of a muscle tension disorder. They are therefore very non-specific. The classic endoscopic signs attributable to LPR can also be found, at least to a degree, when there is no LPR. In the absence of classic LPR symptoms and clinical signs, then this diagnosis should be questioned, as it is arguably overdiagnosed in clinical practice.
An underlying neuromuscular motility or tension disorder is probably the most common underlying problem, although this is impossible to diagnose. Disorders of motor function have been demonstrated in globus patients, including elevation of cricopharyngeal sphincter pressure, midoesophageal dysmotility and poor lower oesophageal sphincter relaxation, but there is still debate as to whether these are primary or secondary phenomena. There is also debate as to whether these findings may interrelate with psychological distress. Furthermore, many patients found themselves in the viscous cycle of having the globus symptom, repeatedly throat clearing, which then makes the muscle tension (especially cricopharyngeus muscle tension) worse, leading to a worsening perception of symptoms, further throat clearing, and so on.