“A poem begins with a lump in the throat; a homesickness or a love sickness. It is a reaching-out toward expression; an effort to find fulfillment. A complete poem is one where an emotion has found its thought and the thought has found words.” --Robert Frost
ENT doctors see this often: the patient who presents with a sense of something in the throat, a lump or foreign body stuck down there that is neither painful, physically evident, nor impedes the passage of food or liquids upon swallowing.
If after a thorough ENT and neck exam, often including a fiberoptic endoscopy of the throat and larynx (voice box), and having found no abnormal or concerning findings, I’ll then ask about stress and anxiety.
And it seems 9 times out of 10 the patient has one or both of these issues. In fact, studies have shown over 90% of patients with this sensation have an exacerbation during times of higher emotional intensity (see reference below).
This phenomenon is known as globus pharyngeus, once called globus hystericus, due to the very nature of it being related to anxiety. It is a sense of something lodged in the throat without dysphagia (difficulty swallowing), odynophagia (pain with swallowing) and most often noted not while eating or drinking (which in some patients improves the symptom) but only when dry-swallowing, i.e., swallowing one’s saliva and nothing more.
Stress can cause one to tighten and tense the neck muscles around the larynx. As the drawing above shows, there are quite a few muscles over the larynx; the ones shown are the strap muscles. Tensing or tightening these strap muscles places pressure on the upper trachea, cricoid and larynx, and all three are right in front of the pharynx and esophagus (the tube where food passes to the stomach). There are also muscles behind the larynx and the pharynx (throat) itself, some of which wrap around both structures and tension in these areas can create that globus sensation. If a patient repeatedly swallows to overcome this sensation, the muscles tighten again, exacerbating the globus sensation, creating a vicious cycle, which can also exacerbate stress or anxiety.
I saw more patients with globus during the COVID pandemic. When asked about stress and/or anxiety, many patients said something to the effect of, “it’s this pandemic…it really is stressing me out!”
Side note: gastroesophageal reflux disease (GERD) can also cause globus, but stress and anxiety can increase risk of GERD. Often patients with GERD will have other symptoms of acid reflux such as heartburn (dyspepsia) or feeling reflux of acid coming up the chest or into the throat. These patients are often treated with diet and behavior means (i.e., avoiding spicy foods, too much caffeine, avoid eating a few hours before bedtime, elevating the head when sleeping), and medical therapy such as famotidine and omeprazole, both available over-the-counter (OTC). However, often those patients with anxiety-induced globus notice no improvement with GERD therapy.
Sometimes anxiety is revealed (or if existing before, is heightened) after a fiberoptic laryngoscopy, where the numbing agent (lidocaine) used to anesthetize the nose and throat intensifies the globus sensation. I’ll warn patients who seem anxious or have a history of anxiety to be aware of this, that sometimes they may feel a bit panicky when the throat gets numb. Some of the more anxious folks will swallow repeatedly in attempt to clear the globus sensation, which then cycles over and over and worsens the globus and the anxiety. After the scope is done and nothing is found, I reassure the patient their airway is wide open (having just viewed it) and that the anesthetic causing this sensation will wear off.
I also explain that if there was a lesion or a tumor, the lidocaine should have lessened the sensation, not worsen it.
Much of this passes quickly particularly once the patient relaxes and is reassured of a normal exam.
To
further illustrate this concept to patients, I’ll explain that the sensation of
globus is often used in older literature--though not the word itself--as a
metaphor to describe the feeling of a lump or a tightness in the throat during
moments of strong emotion, such as deep sadness, fear or anxiety. The quote from Robert Frost is one example
that elaborates this well.
©Randall S. Fong, M.D.
Reference: Bong EL, Gwang HK. Globus pharyngeus: A review of its etiology, diagnosis and treatment. World Journal of Gastroenterology 2012 May 28; 18(20): 2462-2471
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medicine, health and the weirdness of life in general, check out the rest of
the blog site at randallfong.blogspot.com
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