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A Lump in the Throat: Understanding Globus Sensation

Globus sensation—that stubborn, invisible lump in the throat- can be incredibly distressing for patients and perplexing for clinicians. This month on the RefluxRaft blog, we’re highlighting a common yet misunderstood condition. We’re joined again by George Barnes, MS, CCC-SLP, BCS-S, a Board-Certified Specialist in Swallowing and Swallowing Disorders. George is nationally recognized for his expertise in dysphagia, reflux, and aerodigestive disorders. In this in-depth article, he shares his clinical insight on the causes of globus, why it so often defies a straightforward diagnosis, and how a deeper understanding of the reflux-swallowing connection can open new doors to relief.

If you or your patients have ever felt that nagging lump with no clear cause, keep reading.

“There’s a lump in my throat when I swallow. I feel it right here.” The patient points to the throat area, specifically around the area of the thyroid notch, and runs her finger from just above it to just below it. “It’s getting worse month by month. I’ve been to every doctor under the sun. I don’t know what to do anymore.”

The number of times patients have come to me with this complaint is staggering. It’s frustratingly elusive and nearly impossible to identify, let alone treat, and it’s got a name… Globus pharyngeus (or simply globus or globus sensation): The complaint of a lump stuck in the throat, a persistent tightening, or the sensation of something stuck there that just won't go away. It's a truly baffling and often frustrating experience that many patients describe as such. 

This sensation is far more common than you might think, affecting almost half of healthy adults in community-based studies. It's such a frequent complaint that it accounts for about 4% of all referrals to otolaryngology departments.

While it might sound like a simple complaint, globus is anything but. Its etiology is often unclear and multifactorial, making diagnosis and effective treatment a significant challenge for the medical community. For thousands of years, it was even inaccurately attributed to underlying psychiatric illness and thought to affect only women; referred to as “globus hystericus” for that reason. Thankfully, we've moved beyond that outdated idea, as studies show it affects men and women equally, though women are just more likely to seek medical attention.

So, what exactly is behind this unsettling sensation? Let’s try to break it down…

The Usual Suspects: From Reflux to the Mind-Body Connection

Reflux is often considered a significant contributing factor to globus sensation. It's thought that the sensation originates from inflammation and irritation of the throat's lining, directly caused by stomach contents. This can happen directly through laryngopharyngeal reflux (LPR), where stomach contents move beyond the muscle at the top of your esophagus (upper esophageal sphincter - UES) and irritate the larynx (voice box), pharynx (throat), and even the lining of your windpipe and lungs  Repetitive trauma like chronic coughing and throat clearing can amplify the problem.

You see, our bodies are incredibly sensitive to inflammation and irritation, and this is especially the case in the sensitive areas of the upper airway. Studies have reported reflux symptoms in a significant number of patients with globus, with some suggesting that GERD is the primary cause in as much as 68% of cases. 

However, this is where it gets complicated: others have reported conflicting results, noting that globus can exist in patients without heartburn or indigestion and often doesn't respond to common reflux therapies. This suggests that while reflux is a plausible cause for a subgroup, it certainly may not explain it in all cases.

This brings us to another major player: psychological factors and stress. Psychosocial distress syndromes like anxiety and depression are frequently found in globus patients. Some estimates suggest that up to 96% of globus patients reported symptom onset following highly negative psychosocial events. It's thought that increased muscle tension and a heightened mental state can create a focus on existing sensations, alerting the patient to a problem that appears worse than it actually is. 

To better understand this concept, think about your body’s control center, the autonomic nervous system. This control center helps your heart, stomach, and other parts work without you even thinking about it. It’s like a robot that controls our most essential functions. Sometimes, when people feel stressed, this control center can get a little mixed up in how it talks to different parts of the body, especially the heart and the stomach. When this happens, it's not just "all in your head" (which is what "psychosomatic" used to mean). It's actually because the special connection between your brain and your stomach (the "brain-gut axis") isn't working quite right. This can make someone with globus feel an incessant and growing lump in the throat when there is nothing to actually be found there when we take a look.

As if this situation is complex enough, I’ll throw some more potential factors in there which also can contribute to globus sensation:

The Diagnostic Maze: Finding the Right Path

Given the multifactorial nature of globus, diagnosis can feel like navigating Rome with a map of Paris. Historically, extensive workups were common, but many investigations often yielded negative results, adding to patient anxiety and healthcare costs. The good news is that for patients with an isolated complaint of globus pharyngeus, the overall incidence of developing head and neck cancer is relatively low – about 1% over a four-year period in one large study. This is reassuring news for both patients and clinicians and will hopefully relieve more than 1% of the patients’ anxiety. 

So what can we do to help? Recognizing "red flag" symptoms is crucial. These include the following symptoms: 

The presence of any of these should prompt urgent referral and further investigation to rule out malignancy.

For patients without these red flags, a comprehensive head and neck examination, including a fiberoptic nasolaryngopharyngoscopy, is a key step. It’s important to note that tests like barium swallows, neck CTs, and neck ultrasounds are frequently ordered, but rarely yield findings that change clinical management when globus is isolated.

However, instrumental studies like a modified barium swallow study (MBSS), also known as a videofluoroscopic evaluation of swallowing (VFSS) may be more sensitive in identifying subtle abnormalities. Further, high-resolution esophageal manometry and 24-hour pH studies are considered gold standards for motility disorders and reflux, respectively, and can reveal underlying issues.

Management: A Tailored Approach

Since there's no single cause, a "one-size-fits-all" treatment for globus simply doesn't exist. Management often centers on patient reassurance and counseling. For many, simply knowing that a serious condition has been ruled out can significantly improve symptoms.

Here's a look at some common management strategies:

The journey of understanding and managing the globus pharyngeus is constantly evolving. As clinicians, our role is to be compassionate guides, leveraging our expertise and the latest research to help patients navigate this complex condition and find a path toward relief and improved quality of life for our patients. We must remember that often, there are no right or wrong answers; there are only unbeaten paths that need to be explored to determine which is the best for each specific patient. 

Managing this condition requires more than a one-size-fits-all approach; it necessitates curiosity, compassion, and collaboration across various specialties.

About the Author:
George Barnes, MS, CCC-SLP, BCS-S, is a Board-Certified Specialist in Swallowing and Swallowing Disorders with extensive clinical experience in reflux, dysphagia, and aerodigestive function. Known for his evidence-based, patient-centered approach, George advocates for comprehensive evaluation and targeted care plans that address the full scope of swallowing disorders, especially those that defy easy answers. He’s passionate about educating clinicians and empowering patients to understand the root causes of their symptoms better.

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