Globus sensation is characterized by the feeling of a lump or mass in the throat, unrelated to swallowing, when no mass is present. (See Neck Mass if a mass is present.)
Etiology of Globus Sensation
No specific etiology or physiologic mechanism has been established. Some studies suggest that elevated cricopharyngeal (upper esophageal sphincter) pressure or abnormal hypopharyngeal motility occur during the time of symptoms. The sensation may also result from gastroesophageal reflux disease (GERD) or from frequent swallowing and drying of the throat associated with anxiety or another emotional state. Although not associated with stress factors or a specific psychiatric disorder, globus sensation may be a symptom of certain mood states (eg, grief, pride); some patients may have a predisposition to this response.
Disorders that can be confused with globus sensation include cricopharyngeal (upper esophageal) webs, symptomatic distal esophageal spasm, GERD, skeletal muscle disorders (eg, myasthenia gravis, myotonia dystrophica, inflammatory myopathy), eosinophilic esophagitis, and mass lesions in the neck or mediastinum that cause esophageal compression.
Evaluation of Globus Sensation
The main goal is to distinguish globus sensation from true dysphagia, which suggests a structural or motor disorder of the pharynx or esophagus.
History
History of present illness should elicit a clear description of the symptom, particularly as to whether there is any pain with swallowing or difficulty swallowing (including sensation of food sticking). Timing of symptoms is important, particularly whether it occurs with eating or drinking or is independent of those activities; association with emotional events should be queried specifically.
Review of systems seeks weight loss (as evidence of a swallowing disorder) and symptoms of muscle weakness.
Past medical history should include known neurologic diagnoses, particularly those causing weakness.
Physical examination
The neck and floor of the mouth are palpated for masses. The oropharynx is inspected (including by direct laryngoscopy). Swallowing (of water and a solid food such as crackers) should be observed. Neurologic examination with particular attention to motor function is important.
Red flags
The following findings are of particular concern:
Neck or throat pain
Weight loss
Abrupt onset
Pain, choking, or difficulty with swallowing
Regurgitation of food
Muscle weakness
Palpable or visible mass
Progressive worsening of symptoms
Interpretation of findings
Symptoms unrelated to swallowing, with no pain or difficulty with swallowing, or sensation of food sticking in the throat in a patient with a normal examination imply globus sensation. Any red flag findings or abnormal findings on examination suggest a mechanical or motor disorder of swallowing. Chronic symptoms that occur during unresolved or pathologic grief and that may be relieved by crying suggest globus sensation.
Testing
Patients with findings typical of globus sensation need no testing.
If the diagnosis is unclear or the clinician cannot adequately visualize the pharynx, testing as for dysphagia is done. Typical tests include clinical swallow evaluation, plain or video esophagography (video barium swallow), measurement of swallowing time, chest radiograph, and esophageal manometry.
Treatment of Globus Sensation
Treatment of globus sensation involves reassurance and sympathetic concern. No medication is of proven benefit.
Underlying depression, anxiety, or other behavioral disturbances should be managed supportively, with psychiatric referral if necessary. At times, communicating to the patient the association between symptoms and mood state can be beneficial.
Key Points
Globus symptoms are unrelated to swallowing.
Tests are not needed unless symptoms are related to swallowing, examination is abnormal, or there are red flag findings.
