© Springer International Publishing AG 2018Eytan Bardan and Reza Shaker (eds.)Gastrointestinal Motility Disorders doi.org/10.1007/978-3-319-59352-4_6
6. Globus Sensation
Department of Gastroenterology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
KeywordsGlobus sensationGastroesophageal refluxForeign bodySomatizationEsophageal inlet patch
Question 1: What Is Globus Sensation and Why Did This Happen to Me?
Answer: First of all, you should know that globus sensation is a benign functional esophageal problem, not associated with severe life-threatening conditions. Globus sensation is a recurring or persistent feeling of a lump or foreign body in the throat. This sensation can come and go and it does not interfere with your eating and drinking that typically relieve your disturbing sensation. Globus sensation is a common problem and it is estimated that it accounts for almost 4% of patient visits to an ENT specialist. In one study it was found that globus sensation was reported, at least once in a lifetime, by up to 46% of otherwise healthy individuals. Globus affects women and men equally and can affect anyone of any age even though it is much more common in people of middle age. The cause of globus is uncertain, meaning we do not completely understand the cause of this condition. Furthermore, it is not completely understood why in someone with globus sensation, when trying to swallow saliva, swallowing is felt to be disordered (to the point they feel a sensation of a lump in the throat) and, when food is swallowed, swallowing occurs without any problem. The proposed mechanisms that may cause globus sensation include visceral hypersensitivity, motor abnormalities of the upper esophageal sphincter (UES), and psychological comorbidity. Although all have been associated with globus sensation, none of these mechanisms is based on robust evidence. As a result, there are no widely accepted standard investigations or treatment strategies for this disorder.
Brief Review of Literature
Globus sensation is a recurring or persistent feeling of a lump or foreign body in the throat . This may also manifest as feeling of a retained food bolus or tightness in the midline between the thyroid cartilage and sternal notch. Globus sensation is not associated with painful swallowing (odynophagia) or difficulty in swallowing food (dysphagia). It should be noted that patients with globus sensation report that symptoms occur primarily when swallowing saliva (dry swallow) or in between meals.
According to the most recent diagnostic criteria for functional esophageal disorders (Rome IV, 2016) globus requires the absence of an underlying structural lesion, GERD, mucosal abnormalities such as a gastric inlet patch (heterotropic gastric mucosa in the upper esophagus), or an esophageal motility disorder .
Globus sensation is considered to be quite common but there are not enough reliable clinical studies to estimate the actual prevalence of this disorder. It is estimated that globus accounts for almost 4% of visits to ENT specialists. In one study, globus sensation was reported (at least once) by up to 46% of 147 apparently healthy individuals . Globus sensation is prevalent equally in men and women; however women are more likely to seek health care for this sensation. It is most common in individuals of middle age but it can affect anyone of any age. It is more common in urban dwellers compared to those who live in a rural environment. Globus sensation is a chronic condition as symptoms persist for more than 3 years in most of the patients (75%) and even after 7 years in almost half of them.
Although the pathophysiology is unclear, there are several theories including visceral hypersensitivity, gastroesophageal reflux, esophageal motor disorder, and psychological comorbidity.
This refers to a phenomenon whereby normal stimuli or signals which are derived from the throat and transmitted to the brain undergo pathological processing in the central nervous system (CNS) during which the input is abnormally amplified. This information is translated into an unpleasant sensation such as globus (lump or tightness in the throat). Evidence for the mechanism of visceral hypersensitivity in patients with globus sensation is derived from well-designed clinical studies that assessed the response to esophageal balloon distention. From these studies it was demonstrated that compared with healthy controls, patients with globus sensation reported of symptoms at lower distending thresholds, suggesting the presence of esophageal hypersensitivity . In another study, as compared with healthy controls, only patients with globus reported that during esophageal balloon distention they felt globus sensation in the suprasternal notch, suggesting that globus may represent an aberrant central processing of esophageal stimuli.
Patients with globus sensation have been assessed by stationary esophageal manometry in an attempt to find clues for a possible motoric dysfunction which might explain the occurrence of symptoms. Thus far, however, results have not shown any consistent evidence which attributes globus to malfunction of the upper esophageal sphincter (UES). There have been some reports of abnormal UES function such as hypercontractility of the UES (hypertensive UES). However, in more recent studies that employ high-resolution manometry (HRM), these findings were not confirmed, and researchers found no difference in UES mechanics between controls and those with globus sensation . Recently, high-resolution manometry has revealed a number of patterns of UES pathology, including hyperdynamic upper esophageal sphincter inspiratory pressure and high upper esophageal sphincter post-swallow residual pressure among patients with globus. Although these might correlate with symptoms, there is no evidence that these findings are related to disease pathogenesis. Furthermore, in the face of a completely normal food-induced oropharyngeal swallowing process, the issue of a major esophageal motor disorder does not seem to be likely. The same holds true for an anatomic abnormality, including the cricopharyngeal bar, as the anatomy of the oropharyngeal cavity in patients with globus sensation is completely normal.
Globus may itself represent an atypical manifestation of the GERD spectrum and as a result more patients with globus sensation report also of reflux symptoms. For this reason GERD must be thoroughly excluded prior to establishing a diagnosis of globus sensation. According to the recent Rome IV consensus for the diagnosis of globus sensation (described below) even a potentially acid-producing esophageal inlet patch of heterotropic gastric mucosa precludes a diagnosis of globus sensation. Thus far a strong causal relationship between GERD and globus has not been established . In fact, the response rate of globus sensation to PPI therapy is low and there is only anecdotal evidence that patients with globus are more likely than controls to have abnormal pH studies. Overall, it seems that GERD plays a minor role in the pathophysiology of globus meaning that if a PPI trial succeeds the diagnosis is GERD with globus and if not one should evaluate for other etiologies, mainly major esophageal motor disorder and psychological comorbidity that induces globus sensation.
Psychiatric illness, particularly anxiety and depression, is common in patients with globus sensation and may predispose, precipitate, exacerbate, or perpetuate symptoms. By using self-reported questionnaires that evaluate for neuroticism, introversion, anxiety, and depression, it was found that patients with globus sensation score higher than healthy controls [7, 8]. In addition, women with globus sensation demonstrated a higher prevalence of anxiety and somatic concerns [9–11]. However, despite the aforementioned observations, no specific psychological characteristic or specific “hysterical” personality traits have been identified in patients with globus. Thus, the commonly used term “globus hystericus ” is a misnomer and should no longer be applied . Stressful life events that preceded the onset of globus have been reported in the literature, suggesting stress as a risk factor in globus generation or exacerbation . In fact, acute stress has been reported in the majority (97%) of sufferers as a precipitating factor of globus exacerbation.
An association between chronic thyroiditis and globus sensation has been described in many observational studies. In a recent cohort of 92 subjects attending a thyroid clinic, 35% reported globus sensation and 39% had ultrasonographic evidence of chronic thyroiditis . Overall, the risk of globus sensation was calculated as 3.7-fold higher in patients with chronic thyroiditis. Secondly, sleep disorders are associated with globus sensation. In a cohort of 3360 healthy volunteers, sleep disorders were present in a significantly higher proportion of those reporting globus sensation (23.7%), compared to 13.6% among those with globus sensation . Thirdly, globus sensation can occasionally be a result of pharyngeal, laryngeal, or upper esophageal pathology, including cysts and benign or malignant neoplasms. For this reason a thorough examination by an ENT surgeon is the recommended first step for the investigation of globus sensation.
Question 2: How Is Globus Diagnosed, What Tests Should Be Done?
Answer: Investigation includes as first steps a careful history taking and naso-oral inspection, performed by an ENT specialist, preferably using a laryngoscope. Globus sensation is considered a “diagnosis of exclusion.” This means that there is no specific test which confirms this condition. Instead, the diagnosis is made after having tests to be sure that you do not have a more serious condition.
If there is no finding in your examination by the ENT specialist, the next step is to start treatment with PPIs, twice daily, half an hour before a meal, and on empty stomach. Treatment should be continued for a period of 1–2 months. In the case your symptoms improved, your diagnosis is GERD with globus and you should continue PPI therapy with the lower effective dose. In the case of treatment failure, it is recommended to perform an upper endoscopy and esophageal manometry to rule out structural and motility disorders of the esophagus.
Brief Review of Literature: Clinical Management
History and Physical Examination
Diagnosis is made primarily by a careful history taking and by excluding structural lesion, esophageal dysmotility, and GERD. In clinical practice, globus is highly suspected in patients with a sensation of a lump or foreign body in the throat and the absence of heartburn, regurgitation, dysphagia, and odynophagia (symptoms which suggest GERD and dysmotility). It is crucial to differentiate between globus sensation and dysphagia, since dysphagia may implicate a more severe condition and consequently requires an invasive approach, early in the investigation stage. The diagnoses of odynophagia or weight loss need to be excluded as well. Examination by an ENT specialist is recommended as the first step. This should include physical examination of the neck (thyroid neck/tonsillar mass, cervical adenopathy) and examination of the pharynx by laryngoscope. Globus sensation can occur in association with other symptoms of laryngeal dysfunction such as hoarseness (especially in smokers that are at risk for laryngeal cancer) which should prompt ENT evaluation. The clinician should be alert for any risk factors of laryngeal malignancy, including a past history of neck or head radiation, smoking, and alcohol abuse. If present, a thorough ENT examination should be expedited.
The most widely accepted diagnostic criteria for globus sensation are the Rome IV (2016). Criteria must be fulfilled for the past 3 months with symptom onset at least 6 months before diagnosis with a frequency of at least once a week . All of the following three criteria must be fulfilled: (1) Persistent or intermittent, nonpainful, sensation of a lump or foreign body in the throat with no structural lesion identified on physical examination, laryngoscopy, or endoscopy. The sensation occurs between meals, and is not associated with dysphagia, odynophagia, or an esophageal inlet patch. (2) Gastroesophageal reflux or eosinophilic esophagitis is not the cause of the symptom. (3) Major esophageal motor disorders are not present (such as achalasia/EGJ outflow obstruction, diffuse esophageal spasm, jackhammer esophagus, absent peristalsis).
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