Globus Presents Diagnostic Challenge for Otolaryngologists

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.”