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Article
Globus Hystericus
Globus is the term given to the sensation of a lump in the throat causing difficulty with swallowing when there is no physical cause. One can't, of course, know there is no physical cause unless it's been excluded.
Globus hystericus is a Freudian diagnosis. It is used today to describe far more than neurosis. Those that follow a URI are due to patient awareness of their epiglottis and symptoms dissipate after examination to R/O cancer. Explanation is all that is required. Many describe this as a lump in the throat.
The most common cause is gastroesophageal reflux disease - GERD. The Primary Care Physician´s concern and responsibility is to rule throat cancer or other serious malady.
Another common globus diagnosis is psychiatric, a diagnosis made in part by excluding pathology and in part by identifying the stress or neurosis predisposing to the pharyngeal constrictor muscle spasms.
GERD is treated by antacids, bland diet, small evening meals and elevation of the head of the bed, (not with pillows, but rather by placing six inch blocks under the head bed posts) OR the above plus gastric acid suppression. While the suppressors are expensive, failure to make a diagnosis is also expensive (additional visits and tests). Treating with GERD precautions plus a 30 day trial of h.s. gastric suppression is often worthwhile.
By this time in the treatment algorithm you need to authoritatively tell the patient, "there is no tumor." The yield for fiberoptic laryngoscopy for globus hystericus is low, but the patient needs this level of invasive examination. Fiberoptic laryngoscopy also helps confirm the GERD diagnoses.
The yield of Ba swallow for the diagnosis of globus is essentially zero, but the Ba swallow is less expensive than multiple ENT and Psychiatric consultations.
At this point you have either missed the diagnosis or have a difficult patient on your hands. ENT and Psych evaluations are the only way you will come to resolution.
Overview of Globus
Globus hystericus is a Freudian term and while it is true, a percentage of patients presenting with this feeling of a lump or sore in their throat associated with swallowing will have stress as an underlying factor, many are organic in nature. Statistically, the most common cause is gastroesophageal reflux disease. If the patient is a smoker, tumor in the pharynx, hypopharynx, larynx and cervical esophagus must be excluded. This is most easily performed by obtaining an ENT consultation, where a good pharyngeal, hypopharyngeal and laryngeal examination should be performed either by mirror or by fiberoptic exam and that the physician will palpate the oral cavity and the oropharynx.
For all others with globus, an empirical treatment for reflux disease is recommended. For those who fail the reflux treatment, a fiberoptic laryngoscopy is mandatory. If negative, and high suspicion that the complaint is a stress related complaint, stress reduction or psychotherapy is required. If the patient is not going to be happy with this, a barium swallow with a cervical cine can be ordered. This is rarely productive, for patients with cervical tumors, diverticula or other obstructions rarely present with a lump in the throat type history. Nonetheless, I am sure an occasional abnormality is discovered and in any case it provides the primary care provider sufficient information to tell the patient there is no tumor.
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References:
February 2000
www-surgery.ucsd.edu/ent/DAVIDSON/Pathway/Globus.htm
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