The Lump in the Throat (a.k.a. Globus Pharyngeus)
"Help! There is a lump in my throat!" This complaint may be expressed at any age or gender. This lump in the throat sensation (also known as globus pharyngeus or hystericus), is a common complaint that many patients have when presenting to their physician (if you can actually see or feel a mass in the neck, click here for more information). This lump or swollen sensation in the neck is most often described as "annoying," but not painful.
The sensation is more pronounced when swallowing and may even interfere somewhat with swallowing whether it be solids or liquids. Often, a person may feel compelled to swallow a second or third time to make sure things get down. The lump itself is described to be roughly the size of a golf ball or as small as a vitamin pill and is precisely located in the middle of the neck right above the sternum and below the Adam's Apple.
One must first understand a bit of anatomy in this region in order to understand the various causes of globus and their treatment.
The midline external neck landmarks going from superior to inferior is composed of the chin, hyoid bone, Adam's Apple (laryngeal incisure), thyroid cartilage, cricoid cartilage, rings of the trachea (windpipe), and finally sternum. In the photo, the person is pointing exactly on the cricoid cartilage, which coincidentally, is where individuals with globus pharyngeus complain the lump sensation is located. Landmarks are identified below (modification of image taken from Wikipedia).
Behind and anchored to the cricoid cartilage, there is a muscle called the cricopharyngeal muscle that makes a sling around the esophagus (or swallowing tube that leads to the stomach from the mouth). This muscle acts like a sphincter to prevent food from coming back into the mouth after swallowing. This sphincteric muscle is what causes the lump sensation in the throat when it becomes too tight for one reason or another!
So, why would it become tight resulting in the lump sensation?
Reflux may cause this muscle to tighten up in order to prevent acid (and even non-acid mucus reflux) from the stomach from spilling up into the voicebox and mouth. Heartburn is NOT usually present, though treatment with anti-reflux medications is the same. Read more about reflux here.
Increased stress may cause this muscle to constrict more strongly, exactly like the lump that forms in the throat when a person is trying to hold back from crying while watching a very sad movie. Indeed, we see quite a few patients with globus who are in the middle of a divorce, students in the middle of final exams, death in the family, workplace strife (hate the boss or co-worker), etc.
Reflux and stress are by far the most common causes of globus. Rarely, cricopharyngeal muscle or esophageal pathology may also cause this sensation when the muscle scars, hypertrophies, or becomes chronically spastic or the lining of the esophagus develops a ring, shelf, or stricture. Even more rarely, a Zenker's Diverticulum or eosinophilic esophagitis may be present.
A mucosal lesion may cause this sensation. Such lesions may be due to trauma (swallowing a small piece of bone) or ulcer ("canker" sore of the throat). In this particular scenario, the sensation is described as slightly off to one side and the size of a peanut.
Lastly, a mass of some kind can cause this sensation. Such masses may include cancer, cysts, granulomas, large thyroid, etc. Keep in mind, however, that though people think their thyroid may be causing their symptoms of globus, only very RARELY is this the case. The only times when the thyroid may be a factor is when it gets so big to the point it becomes clearly obvious (think an orange-sized mass growing out from the neck), or if the thyroid encircles the esophagus which is also exceedingly rare.
In rare cases, the globus sensation is nothing physical at all, but a type of neuropathy (link).
Treatment tries to address the underlying cause of globus pharyngeus. As an initial exam, a baseline fiberoptic endoscopy is performed to visualize the area of concern. With reflux, proton pump inhibitors (ie, Prilosec are often tried for at least 3-4 weeks though in some people, it may take up to 3-6 months for adequate resolution. Non-acidic reflux may also be present for which standard reflux medications do not work as well.
With stress, explanation alone is often sufficient. Should symptoms persist despite addressing external stressors and taking anti-reflux medications for sufficient amount of time, a barium swallow and/or upper esophageal manometry is ordered to assess whether the muscle itself may be abnormal. Additionally, a 24 hour pH probe and multichannel intraluminal impedance testing may be recommended. If the barium swallow comes back abnormal, an esophagoscopy may need to be performed.
For whatever reason, dehydration seems to be a contributing factor for globus and drinking water seems to help in a significant number of patients.
Procedures to relieve cricopharyngeal muscle hypertrophy, spasticity, or scarring include esophageal dilatation with or without botox injection as well as the more aggressive cricopharyngeal myotomy. Typically, barium swallow and manometry testing must be performed prior to these interventions.
When dealing with masses, treatment is usually excision or biopsy for diagnostic purposes.
Eosinophilic esophagitis can only be diagnosed on biopsies taken during EGD (performed by gastroenterologist).
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