Globus
pharyngis is a common condition. It consists of a multitude of symptoms
of which the most prominent one is “ having a lump in the throat”.
We present a retrospective analysis of 10 cases of globus pharyngis
manifesting in a young male population with varying grades of dysphagia;
a contrast to its typical association with anxious, older female patients.
Introduction
Globus sensation is a common condition experienced at some time in
45% of the population. Globus, the latin word for a ball, is a condition
associated with a multitude of symptoms. It is best described as a
constant feeling of a “lump in the throat” or a fullness
in the throat, in the suprasternal region i.e. in the region of the
cervical oesophagus rather than the oropharynx.. It was described
by Hippocrates and constituted the graphic “suffocation
of the mother” which was known to Shakespeare and was a definitive
symptom of hysteria in the seventeenth century. Its propensity in
women and association with psychological conditions was explained
by ancients by attributing the origin of this condition to the uterus,
hence hysteria from the Greek word hysterus, a womb.7
This typical presentation is of immense value to the otolaryngologist.
The patients usually have a normal examination and have no detectable
abnormality. Various explanations have been provided for globus sensation
including hypertensive upper oesophageal sphincter (UOS) pressure,
gastro oesophageal reflux (GORD).3 Globus has been attributed
to other conditions like sinusitis, anterior cervical osteophytes,
overclosure of the bite and has been shown to be associated with females
suffering from psychological disorders.7
However, the aetiology still remains unclear. Treatment essentially
comprises a systematic elimination of other causes of such symptoms
by doing a thorough ENT examination including oesophagoscopy, other
radiological investigations like Barium swallow and also reassurance
and counselling.
Material and Methods
We present a retrospective analysis of 10 male patients diagnosed
as Globus pharyngis, studied over a period of three years from October
1999 - October 2002. All the ten cases went through a protocol consisting
of a detailed history and thorough ENT examination. All patients underwent
barium swallow examination and a direct laryngoscopy and rigid oesophagoscopy
examination. The patients were followed up for a minimum period of
6 months post operatively.
Observations
Six out of a 10 cases (60%) presented with feeling of foreign body
sensation or “lump” in the throat. All of the patients
presented with varying degrees of dysphagia. Six patients (60%) had
feeling of food getting stuck while swallowing while 4 (40%) patients
presented with severe dysphagia. The duration of symptoms the patients
suffered from varied from 15 days to 3 months. All our patients were
vegetarian and were between twenty and thirty years of age.
None of the patients had history of tobacco chewing, chronic alcohol
abuse, or any other major medical illness or surgery in the past.
The patients had no other ear, nose or throat complaint. The routine
otolaryngological examination was normal. The indirect laryngoscopic
examination and routine haematological examinations were normal. All
ten patients underwent Barium swallow examinations. 60% of patients
had normal barium swallow examinations, while the 40% patients who
presented with acute and severe forms of dysphagia had a hold up of
barium at the mid-oesophageal level suggestive of an obstructive pathology.
Direct laryngoscopy and rigid oesophagoscopy was performed on all
patients and was found to be normal in 40 % of the cases. In 60% of
the cases a spasm of the cricopharyngeal sphincter was noted. The
patients were followed up on OPD basis for atleast 6 months post -operatively.
All our patients showed improvements in the symptoms after rigid oesophagoscopy
and reassurance that all investigations were normal.
Discussion
Globus sensation is a very common entity and has a characteristic
presentation where we generally look for the typical patient profile
which is a female patient, in the 4-5th decade of life, with stable
or increasing weight, anxious and a non-smoker. This condition usually
presents in the older age group and is more common in female sex,
occurring in mild forms in 53% women and 35% in men.7 The
most common symptom of presentation is a feeling of “lump in
the throat”. 60% of our patients had a feeling of a “lump”
in the throat. The patients also presented with varying degrees of
dysphagia with 60% of patients having mild dysphagia i.e. feeling
of food getting stuck in the throat and 40% of cases the patients
presented with severe dysphagia, suggestive of obstruction in the
food passage.
Here it is important to note that all our patients were vegetarians
which rules out meat and bones, a common foreign body in adults, as
a cause of symptoms.
In our reviews, we find an atypical presentation of globus in a young
male population who present with varying grades of dysphagia. It is
important to note that Globus hystericus would not be a differential
diagnosis usually in this age group. Hence it is important to keep
this presentation in mind.
Absence of any findings on a thorough ear, nose and throat and radiological
examination is typical and helps to diagnose this condition.2
This correlates well with our findings of a normal ENT examination
in all 10 cases. All our patients as a protocol had barium swallow
examinations. Globus pharyngis may be a presenting symptom of a pharyngeal
or upper oesophageal neoplasm and this is the main reason why barium
swallows are requested. Usually the barium swallows in globus pharyngis
are normal.
 |
|
Fig.
1 : Barium swallow showing horizontal level of barium
simulating a foreign body / tumour at mid oesophageal level.
This patient presented with acute onset severe dysphagia and
had a normal rigid oesophagoscopic examination |
|
Acid reflux (18.5
%) and hiatus hernia (12%) are the commonest findings of a barium
swallow.1 In our review, none of the cases had barium results suggestive
of acid reflux or hiatus hernia. However, 40% of our patients presenting
with severe dysphagia showed a hold-up of barium at mid-oesophageal
level ( Fig. 1). This correlates well with studies which show that
radiological examinations in patients with globus show specific findings
of pharyngeal dysfunction.5 It is also known that upper
oesophageal sphincter hypertonicity is an important aetiological factor
of globus3 and the peculiar findings in the 40% of our
patients can be attributed to the same. As protocol, all our patients
underwent a rigid oesophagoscopy as the association of gastroenterological
disease and globus pharyngis is documented. A study of 105 patients
divides the abnormal findings on oesophagoscopy in two broad categories
namely - i) inflammatory diseases of stomach and duodenum and ii)
disorders of lower oesophageal sphincter.6 Farkkila et
al show that endoscopy is abnormal in 57% of patients with the
commonest findings being antral gastritis and hiatus hernia.4
This value correlates well with our study where 60% of patients had
a detectable abnormality namely - upper oesophageal sphincter hypertonicity
/ cricopharyngeal spasm.
All our patients showed a symptomatic improvement after rigid oesophagoscopy.
This may warrant and justify diagnostic oesophagoscopies for such
symptoms on a routine basis.
Conclusions
1. Globus sensation may present even in a young male usually with
symptoms of mild to severe dysphagia
2. 100% patients show symptomatic improvement after treatment with
rigid oesophagoscopies and reassuarance that everything is normal
3. Barium swallow findings are not always normal as seen usually,
almost 40% of patients may show findings suggestive of obstructive
pathology and in the event of a normal rigid oesophagoscopy it is
important to maintain a high index of suspicion towards “Globus
pharyngis”, as being the possible cause.
4. Cricopharyngeal sphincter spasm is an important finding which must
be looked for as this points to UOS hypertonicity as a cause for the
globus sensation.
References
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Section 3, Chapter 21. 17th Edition. Zelko Gary, publisher 1999.
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DA, Katz PO, Castell DO. Dig Dis Sci 1998 Jul; 43 (7): 1513 - 7.
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