globus pharyngeus , the sensation of something stuck in the throat , has been noted since the time of hippocrates .
purcell first used the term globus hystericus in the early 18th century . in 1968 , malcomson   suggested the term globus pharyngeus as a more accurate description since not all patients with globus were either hysterical or female .  
typically , globus is relieved by ingestion of solids or liquids and tends to be worse on dry swallows .
globus may be associated with throat irritation , soreness , dryness , catarrh , or constant throat clearing .
it forms a large part of ent practice and may account for about 4% of referrals to our outpatient clinics .
the prevalence is much higher in the general population as most people may not present to hospital with it .
a recent study by ali and wilson   found that up to 78% of patients presenting to non - ent clinics had had globus - type symptoms .
despite the high prevalence in the community , the aetiology of globus remains unclear and highly controversial .
it is slowly being accepted that it may be multifactorial and that when it occurs in isolation it rarely hides any sinister pathology .
most of the recent work has suggested several mechanisms in isolation or not uncommonly in combination are to blame for the manifestation of globus pharyngeus ; these include psychological factors , gastro - esophageal reflux ( gor ) , pharyngeal dysmotility , hypertonic upper oesophageal sphincter ( uos ) , and local anatomic abnormalities [ 611 ] . as its earlier name ,
globus hystericus , suggests , there has been a long history of links between globus and psychological factors .
it is the fourth most discriminating symptom of a somatisation disorder after vomiting , aphonia , and painful extremities .
as most of the globus patients are quite rightly referred to ent surgeons rather than to psychiatrists , a psychogenic basis must always be borne in mind .
gale et al .   in a detailed medical and psychological examinations including assessment with the minnesota multiphasic personality inventory ( mmpi ) of 4240 us
this globus group scored higher in nine out of ten of the mmpi clinical scales .
they concluded that in men there is a significant link to depression and somatization disorder and as a result other related treatable psychopathology should be investigated .
when comparing globus patients with other ent patients ( as a control group ) found that globus patients had had more severe life events in the year and less confiding relationships than controls .
the link between gor and globus has been a matter of controversy for over forty years .
they found that 66.6% of the nonreflux globus group and 80% of the gor globus group had significant episodes of reflux ( based on ph monitoring ) . in direct contrast , chen et al . in a similar study found no evidence of reflux in globus patients based on ambulatory ph monitoring .
anandasabapathy and jaffin   using multichannel intraluminal impedance and ph monitoring ( mii - ph ) have suggested that globus may also be due to nonacid ( nar ) reflux .
as mii - ph can detect reflux episodes independent of acid changes , it is allegedly more accurate at picking up proximal reflux .
based on porcine models , pepsin has been shown to increase the levels of laryngeal protective proteins and thus explain the nar link . even though low ph is needed to activate pepsin
, its stability means that it may be activated intracellularly or when the larynx is later exposed to acid .
hypertonicity of the uos has been suggested as a cause of globus , but several studies have yielded conflicting results .
it has long been recognised that the uos pressure profile is asymmetrical , especially when using multilumen catheters . therefore ,
uos pressure measurements obtained using circumferential transducers are regarded as being more reflective of true intraluminal pressure .
sun et al .   looked at twenty - four healthy volunteers and thirty - two patients with globus and found uos pressure to be normal in most of the globus patients and could not suggest it as a possible aetiological factor .
interestingly they found that videofluoroscopic evidence of pharyngeal dysfunction especially laryngeal penetration had a strong association with globus .
, however , showed that perfusion of hcl into the distal oesophagus was related to a sensation of globus associated with a rise in uos pressure .
this rise in pressure was independent of the detection of a rise in ph in the hypopharynx .
recently there have been reports of very subtle changes in anatomy that when rectified have given relief of globus .
the definition of a retroverted epiglottis is if the tip touches the tongue base when the tongue is protruded .
ulug and ulubil   have presented a case of corniculate cartilage subluxation presenting with globus .
other postulated causes include eagles syndrome ( calcified stylohyoid ligament ) , impalpable thyroid nodules , cervical osteophytes , lingual tonsils , or prominent greater cornu of the hyoid .
gastric inlet patches have also been aetiologically linked to globus [ 19 , 20 ] .
these are congenital islands of ectopic gastric mucosa found in the cervical oesophagus . with the incidence of gastric inlet patch being quite common ( 3.6% )
have gone further to suggest that it is h. pylori infection of the inlet patch that causes altered cervical perception and hence globus .
what is worrying about this is that these patches have been associated with both squamous cell carcinomas and adenocarcinomas of the upper oesophagus [ 19 , 22 ] . more interestingly though shiomi et al .  
looked at the mucus in the epipharynx of patients with globus and compared it with that from healthy volunteers , they found that there were significantly increased concentrations of fucose and sialic acid ( the main determinants of mucus viscosity ) in the mucus of those with globus as compared to normal subjects .
lastly , though there is no evidence to suggest this , some ent surgeons believe that globus may  simply  be a local sensory abnormality just like tinnitus .
as with all our patients , the key is in taking a proper history . pointers that would suggest sinister underlying pathology would include dysphagia , aspiration , regurgitation , weight loss , voice change , and pain .
the presence of overt symptoms of gor should be noted . the head and neck should be thoroughly examined . this should include transnasal fibre - optic laryngoscopy ( fol ) or if available transnasal flexible laryngooesophagoscopy ( tno ) .
any further investigation should be based on the findings at history and examination . in ent departments in the uk ,
contrast swallows are the most popular radiological investigations used to investigate globus , with some departments historically using them to screen patients for upper aerodigestive tract malignancy [ 23 , 24 ] .
they have been favoured because they are safe ( compared to rigid endoscopy ) , quick , and believed to increase diagnostic yield .  
one of the authors ( rph ) retrospectively reviewed a series of 1275 patients that had barium swallows .
six hundred and ninety - nine patients had globus and 451 of these patients had globus without sinister symptoms . in these patients , barium swallows did not show any sinister pathology .
another review of barium swallows by hajioff and lowe   looked at 2854 barium swallows from two centres , and of the 2011 patients that presented with globus , none had a worrying abnormality on barium swallow .
only one retrospective case series   has found an association between isolated globus and hypopharyngeal cancer .
two cases out of twenty - three cases were retrospectively found to have malignancies ( a piriform fossa and postcricoid tumour ) .
more recent and larger studies have failed to make a similar association . in the light of
the previously mentioned we do not recommend barium swallows routinely for globus . the diagnostic yield for malignancy is poor though it may reassure the patient .
the main drawback of this is that flexible oesophagoscopy often requires sedation , while rigid endoscopy requires a general anaesthetic and carries a small but significant risk of perforation .
lorenz et al .   carried out flexible endoscopies on patients that had been referred by ent for further investigation of globus , and all of the patients had had a normal outpatient ent examination and barium swallow .
62.7% of the patients were found to have pathology that could possibly have caused their globus though no sinister pathology was noted .
similarly , nagano et al .   in their study found a 36.5% incidence of benign oesophageal pathology in patients with globus on flexible endoscopy , but again no malignancies were identified .
the most common recorded anomalies were cricopharyngeal spasm ( 4.8% ) and reflux ( 4.4% ) .
no tumours were found , and they concluded that rigid endoscopy played a limited role in the investigation of globus .
it combines the main advantages of both conventional flexible and rigid oesophagoscopy with none of the major disadvantages .
there is total examination of the upper digestive tract down to the stomach with the ability to take biopsies at the same time .
it has been shown to be safe with a high patient satisfaction rate . though tno is not yet routinely available in
the uk , we think that it is the ideal investigation for those ent surgeons who want a relatively safe , cheap , and quick way of visualising the upper digestive tract especially the hypopharynx and postcricoid regions . where tno is available ,
we eagerly await studies comparing the diagnostic yield of tno to that of rigid oesophagoscopy . despite the controversies ,
a large number of uk ent surgeons believe that reflux plays a role in globus .
many of us do not use any scores or indices in our assessment of patients with globus .
the reflux symptom index and the reflux finding score are not particularly valid diagnostic tools when used in globus patients .
the glasgow edinburgh throat score ( gets ) has been validated for use in globus but is not widely used . because of the benign nature of globus , we rarely ever ask for ph or impedance studies in our patients .
where there is uncertainty about the aetiology there will be uncertainty about the management . if patients have overt signs or symptoms suggestive of reflux in addition to globus , we would treat them aggressively with a proton pump inhibitor ( ppi ) twice daily and a reflux suppressant for at least 4 months .
a study from the cleveland clinic using a regimen similar to ours has been found to be effective in controlling the symptoms of laryngopharyngeal reflux ( lpr ) .
most of the ent surgeons in the uk seem to be prescribing sub - optimal doses of ppis . in cases where there is globus but with no evidence of gor
two recent meta - analyses of the role of ppis in reflux related laryngeal disease have shown little or no benefit over placebo [ 36 , 37 ] .
they both recommend that more studies are required to define the subgroup of patients that will benefit from ppis .
a few trials have shown that globus symptom scores do improve after a course of speech therapy [ 38 , 39 ] .
what is not clear from these studies is whether there is a specific effect from speech therapy or if improvement is due to increased reassurance .
hypnotically assisted relaxation ( har ) therapy has also been reported in a recent case series   to improve globus sensation regardless of the cause .
manometric uos readings in the patients showed no change before and after har . in cases where there are anatomical anomalies , the trend seems to be excision of the offending local structure , most often some part of the cartilaginous framework of the larynx [ 9 , 10 ] .
these results have to be viewed with caution as the numbers are small with short follow - up intervals
. we must also remember to assess the whole patient and make referrals to the psychiatrists where it is indicated .
therefore in most cases of globus , if the history and examination of the patient suggest no sinister pathology , then reassurance is often enough .
rowley showed that at 7 years about 55% of patients were asymptomatic and none had developed an upper aerodigestive tract malignancy . at the present , we do not recommend any further radiologic or endoscopic examination for the patient with isolated globus .
a complete head and neck examination including fibreoptic laryngoscopy is more than adequate to confidently discharge the classic globus pharyngeus patients .
the introduction of tno in one stop globus clinics has meant that with appropriate training otolaryngologists can nowadays and in selected cases complete a thorough upper aerodigestive tract examination , thus avoiding the need for any other investigations such as barium swallows or oesophagoscopies under general anaesthesia .
overinvestigating these patients can often add unnecessary stress to a group of patients who already seem to have higher levels of depression , anxiety , and other somatic concerns .
in fact the authors believe that both barium swallow and panendoscopy under ga are things of the past and should not form part of the standard globus assessment .
more research needs to be carried out into the aetiology , treatment , and long - term prognosis of persistent globus .
 globus pharyngeus is a common ent condition . 
 this paper reviews the current evidence on globus and gives a rational guide to the management of patients with globus . 
 the aetiology of globus is still unclear though most ent surgeons believe that reflux whether acidic or not plays a significant role . 
 though proton pump inhibitors are used extensively in practice , there is little evidence to support their efficacy . 
 most patients with globus can be discharged after simple office investigations . 
 the role of pepsin - induced laryngeal injury is an exciting concept that needs further study . 
 given the benign nature of globus pharyngeus , in most cases , reassurance rather than treatment or extensive investigation with rigid oesophagoscopy or contrast swallows is all that is needed . 
 we need more research into the aetiology of globus . 
1. Introduction
2. Aetiology
3. Investigation
4. Treatment
5. Conclusion