Globus Pharyngeus

Globus Pharyngeus is a term given when the patient is complaining of a 'feeling of something stuck in the throat'. It is a common symptom and there is no clear understanding of its pathogenesis. It causes concern because of the small risk that it is a symptom of a malignancy in the pharynx or oesophagus.

• Diagnosis
• Possible Causative Factors
• Primary Care Management
• Referral to Secondary Care

Diagnosis

Globus pharyngeus can only be firmly diagnosed after other conditions have been excluded. However, there are a number of pointers to the diagnosis.

• There is no dysphagia for solids or liquids
• Swallowing food relieves the feeling
• There is no pain or soreness
• The symptoms are clearly intermittent
• The history is long with no development of dysphagia

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Possible Causative Factors

The following need to be considered: 

• Acid reflux  - This is probably the single commonest pathologic cause of globus. It is often associated with clearing of throat, and occasional croaky voice. Symptoms are usually worse in the morning. There may be a clear history of acid reflux, but some patients are “silent acid refluxers”
• Steroid inhalers - Steroids used in the management of asthma, may cause dysphonia, but also can produce a globus sensation. This may be caused by secondary Candida infection
• Post nasal drip - Patients often complain that the globus sensation is caused by “catarrh or mucus”. A postnasal drip needs to be considered
• Stress - There is no doubt that globus pharyngeus can be provoked by stress in some patients, but avoid the old term globus hystericus.

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Primary Care Management

If there are no symptoms of pain, soreness or dysphagia in a non-smoker, then the likelihood of malignancy is extremely low, and the patient can be reassured.
If the patient is requesting treatment, then this depends on the supposed causative factor:

• Acid reflux - Avoid late evening meals, and snacks or milky drinks in the evening. Lose weight if appropriate. Proton pump inhibitor at standard dose (or doubled if the patient is already on one) plus Gaviscon Advance 10mls qds after meals and last thing at night. This should be continued for 6 weeks
•  Steroid inhaler related - Consider antifungal such as Fluconazole 50 mg daily for 2 weeks. Ensure proper post-inhaler drink
• Post nasal drip - Try simple saline nasal wash/spray or a steroid nasal spray

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Referral to secondary care

• Urgent
  If there are symptoms of dysphagia for food or liquids, pain or soreness then immediate referral on a cancer referral form should be made to ENT
• Routine
  For those patients with globus pharynygeus with no worrying features, who have failed over a 6 week period with the above management, then refer to secondary care. A barium swallow could be organised

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