Gastroenterologists often participate in the evaluation of ‘throat’ problems, specifically, when they are not voice related. Some of the symptoms patients may have are [i]:
- Want to swallow all the time (excessive clearing of the throat)
- Something runs down throat
- Can’t empty throat when swallowing
- Something stuck in throat
- Discomfort or irritation in throat
- Difficulty in swallowing food
- Food sticking when swallowing
- Throat closing off
- Swelling in throat
- Pain in throat
The typical patient will see an Ear-Nose-and-Throat (ENT) specialist first and they will very often suspect laryngo-esophageal reflux, that is reflux of stomach fluid into the lower throat and voice box. Oftentimes the ENT surgeon recommends an extended therapeutic trial of proton pump inhibitors (antacid medication such as Prilosec) lasting several weeks or a few months. If this doesn’t work, a referral to a gastroenterologist is often made under a theory that non-acid components of the gastric juice such as pepsin are causing the irritation. The gastroenterologist will conduct further investigations before making a diagnosis of “globus pharyngeus” (Lat./Greek for ‘lump in throat’).
How does a gastroenterologist evaluate and treat “globus pharyngeus”?
A globus pharyngeus is defined by our specialty societies as a “persistent or intermittent, painless sensation of a lump or foreign body in the throat with no structural lesion identified on physical examination, laryngoscopy or endoscopy [ii]”. Sometimes patients predominantly report some of the other symptoms in the list above (Glasgow Edinburgh Throat Scale).
A gastroenterologist will typically perform an upper endoscopy, aka esophago-gastroduodenoscopy (EGD), to rule out the above mentioned structural abnormalities. An important point to know is that, unless you specifically look for it, a so-called inlet patch can easily be missed [iii]. However, the absence of an inlet patch is a prerequisite for the diagnosis of globus pharyngeus because this type of esophagus lining can sometimes produce acid and destruction of the inlet patch with heat application can eliminate the throat discomfort.
Furthermore, the globus sensation should only occur between meals (symptoms are no longer present during meals), there is no evidence for reflux disease, and esophageal biopsies show no evidence of eosinophilic esophagitis (a topic for a future post). Moreover, an esophageal manometry (pressure recording of the esophageal muscles in response to swallows) must exclude a major esophageal motility disturbance.
As can be seen from the above, globus pharyngeus is a “diagnosis of exclusion”, but if all of the above was negative or normal, a diagnosis of globus pharyngeus has been established.
What is the reason for globus pharyngeus ?
The short answer is that nobody knows for sure. Historically, globus was thought to be primarily psychological in origin, hence the original name ‘globus hystericus’. Today we acknowledge that psychological factors such as anxiety may play a role but that like in irritable bowel syndrome visceral hypersensitivity and potentially minor esophageal motility abnormalities, especially involving the upper esophageal sphincter, are more important.
How is globus pharyngeus treated?
It is most important that your doctor spends time with you explaining everything in detail and reassure you that the condition usually doesn’t get worse, often gets better by itself, although it may take a while, even years. Many patients will ask: So, I just have to live with it? My answer is, yes, if you can, but there are a number of things we could try if this keeps interfering with your quality of life.
We are assuming that proton pump inhibitors have already been tried. On occasion I will repeat an upper endoscopy even if it has been already done by somebody else to look for an inlet patch as these are sometimes not specifically looked for [iv]. If I am satisfied that the diagnosis is globus, I may refer to speech therapy for pharyngeal relaxation techniques that may be helpful. However, there are not enough studies yet to recommend it across the board. If symptoms are refractory, cognitive behavioral therapy (CBT) essentially teaches patients how to live with their symptoms and limit the impact the symptoms may have on their overall sense of well-being. Finally, small doses of tricyclic antidepressants or even SSRIs such as paroxetine, have been helpful in smaller studies.
Please make an appointment with your physician or Dr. Klaus Gottlieb if you have any questions about throat problems, reflux disease or other GI or Liver concerns.
Main reference: Harvey PR, Theron BT, Trudgill NJ. Managing a patient with globus pharyngeus. Frontline Gastroenterology. 2017 Aug 4:flgastro-2017.
[i] Deary IJ, Wilson JA, Harris MB, MacDougall G. Globus pharyngis: development of a symptom assessment scale. Journal of psychosomatic research. 1995 Feb 1;39(2):203-13.
[ii] Rome IV diagnostic criteria for globus pharyngeus
[iii] Azar C, Jamali F, Tamim H, Abdul-Baki H, Soweid A. Prevalence of endoscopically identified heterotopic gastric mucosa in the proximal esophagus: endoscopist dependent? Journal of clinical gastroenterology. 2007 May 1;41(5):468-71.
[iv] I am looking for text in the endoscopy report that specifically states, “there was no inlet patch”.