Globus pharyngeus: Description, Causes and Risk Factors:
Globus pharyngeus is a common disorder and accounts for 5-6% of all ENT referrals.
The exact aetiology of globus pharyngeus remains unknown. There are many theories as to why people develop this condition. Amongst the popular theories are acid reflux from the stomach, muscular tension of the throat and voice box (larynx), failure of the muscle at the top of the gullet (cricopharyngeus muscle) to relax and stress.
Two basic mechanisms have been proposed to explain the association between acid reflux and the globus pharyngeus, direct irritation and inflammation of the laryngopharynx by retrograde flow of gastric contents, also known as laryngopharyngeal reflux (LPR), vagovagal reflex hypertonicity of the upper esophageal sphincter (UES) triggered by acidification or distention of the distal esophagus.
Smooth muscle tumors of the pharynx and post cricoid lymphangioma, as well as oropharyngeal metastasis of Merkel cell carcinoma, have been reported in patients complaining of globus pharyngeus.
To date much has been published on the proposed aetiology of globus pharyngeus, which still remains poorly elucidated, and many theories have evolved. It has long been held that many of these patients have a psychogenic component to their disorder; however, from the mid-part of the last century the focus shifted to potential organic causes.
The discomfort or irritation in the throat can be made worse by repeatedly clearing the throat or the constant action of swallowing. Stress and anxiety seem to make the problem even more worse.
The symptoms of globus pharyngeus are relatively straightforward
. For the individual suffering with this condition, there seems to be something lodged firmly in the throat. Attempts to swallow the obstruction are not successful, even when drinking a beverage in an attempt to wash it down. In the more severe cases, the individual may feel some discomfort in the upper chest or possibly some pain during the process of swallowing. However, it is still possible to swallow normally, although with less comfort.
The first step of an investigation of globus symptoms should be to take a detailed patient history, paying particular attention to the presence of “high risk” symptoms, associated acid reflux symptoms and psychological problems. Additionally, physicians should perform a physical examination of the neck followed by nasolaryngoscopy, examination of the laryngopharynx, although the routine use of nasolaryngoscopy in patients with typical globus symptoms remains controversial. Patients with typical globus symptoms usually require no further investigation beyond an outpatient nasolaryngoscopy. However, patients with “alarm signs”, such as dysphagia, odynophagia, throat pain, weight loss, hoarseness, and lateralization of pathology, should undergo more extensive evaluation.
There has been no consensus regarding how best to diagnose and manage globus pharyngeus. A study by ENT specialists found that 14% performed no tests on globus patients but rather simply prescribed antacid medication as clinically indicated. The remaining investigated globus symptoms in a variety of ways, including rigid endoscopy, barium swallow, or a combination of these methods.
Treatment tries to address the underlying cause of globus pharyngeus. As an initial exam, a baseline fiberoptic endoscopy is performed to visualize the area of concern. With reflux, proton pump inhibitors (PPIs) are often tried for at least 3-4 weeks though in some people, it may take up to 3-6 months for adequate resolution.
With stress, explanation alone is often sufficient. Should symptoms persist despite addressing external stressors and taking anti-reflux medications for sufficient amount of time, a barium swallow and/or upper esophageal manometry is ordered to assess whether the muscle itself may be abnormal. Additionally, a 24 hour pH probe and multichannel intraluminal impedance testing may be recommended. If the barium swallow comes back abnormal, an esophagogastroduodenoscopy (EGD) may be ordered which is performed by a gastroenterologist.
Surgical Options: Procedures to relieve cricopharyngeal muscle hypertrophy
, spasticity, or scarring include esophageal dilatation with or without Botox injection as well as the more aggressive cricopharyngeal myotomy. Typically, barium swallow and manometry testing must be performed prior to these interventions.
In cases with negative clinical investigations and consistent globus symptom, other treatment strategies, including anti-depressants, Speech Therapy, and Cognitive-Behavioral Therapy, should be considered.
NOTE: The above information is educational purpose. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.
DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.