Patient Presentation
A 14-year-old female came to clinic because of concerns for “something stuck in my throat.” She complained that this had been occurring for several weeks with her noticing the symptoms more often and they were now becoming more irritating. She had a history of mold and other environmental allergies for which she took antihistamines but these didn’t seem to be working. She also said she had had several colds during the same time period. “I can swallow, but the mucous just seems to be a big blob in my throat. It’s really irritating,” she stated. She also related that she was drinking sips of water which helped, but that she then didn’t want to do that because she then had to urinate frequently. She also noted that it was better when she ate, and was not a problem when she was distracted or sleeping. She said she hadn’t choked on anything and denied any foreign body ingestion. She did say that she had coughing but that it was more around the time she knew she had a cold. She denied any actual pain or burning sensations, nausea, emesis, or abnormal tastes in her mouth. She had no voice changes or hoarseness. She also denied any problems with her ears, mouth including dental issues, and hadn’t noticed any abnormal swellings in her neck or other locations, nor any abnormal bruising or bleeding. She had full range of motion of her neck. She denied any abnormal eating patterns.
The past medical history was positive for generalized anxiety disorder that she was receiving psychotherapy for. She also had a history of some obsessive symptoms but did not have a specific related diagnosis.
The review of systems was otherwise normal.
The pertinent physical exam showed a healthy female with normal vital signs. Her weight was consistent and there was no weight loss. HEENT examination was noted to have some allergic shiners and some boggy nasal turbinates with post-nasal drip and cobblestoning of her posterior pharynx. She had no lymphadenopathy, nor masses and had a normal size thyroid gland. She had normal neck motion. The rest of her examination was normal.
The diagnosis of allergic rhinitis that was not adequately controlled was made along with probable globus sensation related to it. The pediatrician recommended that she increase her antihistamines and also start a nasal steroid medication. “These should help with the mucous not accumulating so much. Some people also have this sensation in their throat we call a globus sensation. Like a glob in your throat. It doesn’t cause problems but can still be there. It usually goes away with time, so I think between improving your allergies and drinking more water this should help with the feeling. Just remember if it starts to bother you that it is benign. Another option would be to suck on some hard candies or chew some gum. That may keep your saliva going more and also help.”
The patient’s clinical course 1 month later when she returned for her well examination showed that her symptoms had improved but hadn’t totally resolved. “I keep drinking the water and remember what you said about this being okay. I still don’t have any pain and most of it has gone away,” she stated.
Discussion
Globus sensation (GS or globus hystericus or globus pharyngeus) is a chronic functional disorder that is a “…persistent or intermittent non-painful sensation of a lump or foreign body in the throat localized to the midline between the thyroid cartilage and sternal notch….” Some patients have problems localizing the sensation and may say it has a laterality. It is described in many different terms including fullness, tightness, tickling, or pruritic. Patients may describe it as choking, food being retained, or having mucus accumulate that cannot be adequately cleared. There is no actual impairment in swallowing and eating or drinking may actually improve the sensation.
It is a common complaint with up to 4% of otolaryngology visits for it. It more commonly occurs in adults (peak onset 35-54 years) more than children and occurs more in women. Lifetime prevalence is 22%. Patients with GS more commonly report or have higher test scores for depression, anxiety, sleep problems and hypochondriasis.
Patients with true dysphagia, painful swallowing or weight loss are symptoms for other diseases and not for idiopathic GS. The differential diagnosis includes anatomical abnormalities including benign and malignant masses, esophageal motor problems including achalasia, esophageal spasm or sphincter spasm, thyroid disease and/or surgery, and gastroesophageal reflux disease or laryngopharyngeal reflux. Some patients also may complain of GS when they have increased post-nasal drip or with increased pharyngeal fluid or conversely when they have xerostomia. Some voice problems may also produce this sensation. Evaluation includes history and otolaryngological clinical examination. Additional evaluation if there are concerning symptoms or to make a definitive exclusion diagnosis may also include laryngoscopy, esophagoscopy/upper endoscopy, ultrasound of the neck, pH probes, esophageal manometry and/or trials of proton pump inhibitors.
Learning Point
Explaining the benign nature of the idiopathic GS sensation is often enough reassurance to treat many patients. If an underlying abnormality is found during evaluation then the abnormality is treated accordingly. This includes appropriate treatment for any concomitant psychiatric disorders. Anti-anxiety and depression medications have been used with some success. Proton pump inhibitors as a trial are also commonly used for patients with more chronic symptoms. Other complementary treatments which have been studied include speech pathology therapy help with pharyngeal relation, supragastric belching, and vocal hygiene. Other studies have looked at acupuncture, and Rukkushito, a Japanese herbal medication. For some, humidification and drinking enough water also improve symptoms.
GS is benign without major long-term sequelae with improvement for most but for some patients it can still affect quality of life.
Questions for Further Discussion
1. What are indications for referral to a psychologist or psychiatrist?
2. What causes dysphagia? A review can be found here
3. What causes cough? A review can be found here
Related Cases
- Disease: Globus Sensation | Allergy | Throat Disorders
- Symptom/Presentation: Pain
- Specialty: General Pediatrics | Otolaryngology
- Age: Teenager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Swallowing Disorders and Hayfever.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Jarvenpaa P, Arkkila P, Aaltonen LM. Globus pharyngeus: a review of etiology, diagnostics, and treatment. Eur Arch Otorhinolaryngol. 2018;275(8):1945-1953. doi:10.1007/s00405-018-5041-1
Zerbib F, Rommel N, Pandolfino J, Gyawali CP. ESNM/ANMS Review. Diagnosis and management of globus sensation: A clinical challenge. Neurogastroenterology and Motility. 2020;32(9):e13850. doi:10.1111/nmo.13850
Pang L, Sareen R, Gorecki A. Medical and psychiatric differential diagnoses of pediatric globus sensation: A case study with review discussion. Clinical Child Psychology and Psychiatry 2021;26(4):1053-61. doi:10.1177/13591045211026046
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa