Pharyngoesophageal Dysmotility
in Globus Sensation
Janet A. Wilson, FRCS; Anne Pryde, AIMLS; Juan Piris, DPhil; Paul L. Allan, FRCR;
Cecillia C. A. Macintyre, MSc; Arnold G. D. Maran, MD; Robert C. Heading, MD
\s=b\ Ambulatory esophageal pH monitor-
ing, radiologic examination, endoscopy,
and manometry were undertaken in 142
patients with globus. The results demon-
strate that abnormal gastroesophageal re-
flux occurred in 23% of patients, implying
that, while reflux may be responsible for
globus in some patients, it is not the cause
of globus sensation in the majority of indi-
viduals with this symptom. Comparing pa-
tients with globus and control subjects,
there were no differences in lower esoph-
ageal sphincter pressures, esophageal
body motility, or tonic upper esophageal
sphincter pressures, but patients with glo-
bus exhibited higher pharyngeal and upper
esophageal sphincter after-contraction
pressures during deglutition. The physio-
logical significance of this pharyngeal and
upper esophageal dysmotility is not clear
and it may be no more than a secondary
phenomenon. Alternatively, it may contrib-
ute to the generation of globus, perhaps in
combination with other physical and psy-
chological triggers.
(Arch Otolaryngol Head Neck Surg.
1989;115:1086-1090)
Accepted for publication March 3, 1989.
From the Departments of Otolaryngology (Drs
Wilson and Maran), Medicine (Mrs Pryde and Dr
Heading), Pathology (Dr Piris), Radiology (Dr
Allan), and Medical Statistics Unit (Ms Macin-
tyre), University of Edinburgh, Scotland.
Read, in part, at the seventh British Academic
Conference on Otolaryngology, Glasgow, Scot-
land, July 29,1987.
Reprint requests to Department of Otolaryn-
gology, The Royal Infirmary, Edinburgh, Scotland
(Dr Wilson).
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Globus sensation, feeling
thing in the
a
throat,
of some¬
accounts for
4% to 10% of laryngology referrals12
and is the most common indication for
endoscopy in otolaryngologic practice
in the United Kingdom.3 A wide vari¬
ety of organic explanations has been
proposed.48 The most popular in recent
years has been that globus is an atyp¬
ical manifestation of gastroesoph¬
ageal reflux (GER).9" Previous re¬
ports, all but one uncontrolled, used
clinical and radiological methods to
diagnose GER and claimed a preva¬
lence of up to 93% in patients with
globus.1215 Endoscopie studies, how¬
ever, demonstrated esophagitis in no
more than 12 % of cases.2·16 Manometric
studies have also yielded conflicting
results on the nature of associated
lower17 and upper1819 esophageal dys¬
function. The aim of this study was to
perform a variety of tests of esoph¬
ageal function in a large number of
patients with globus sensation. The
study had the approval of the local
hospitals' ethical committee and all
subjects gave informed consent to par¬
ticipation.
PATIENTS AND METHODS
Patients
One hundred forty-two patients, 110
and 32 men (mean age, 48 years),
women
were studied from 1985 to 1987. All had a
principal complaint of globus sensation and
had been referred to a special 'globus clinic'
for further investigation.
Investigations
All patients underwent a videorecorded
upper gastrointestinal tract series. During
the initial part of the study, 90 patients un¬
derwent routine hématologie and biochem¬
ical screen and roentgenogram of sinuses
and cervical spine. These investigations
were later discontinued on account of low
diagnostic yield. Endoscopy with distal
esophageal and posterior laryngeal biopsy
was performed in 117 patients.
Eighty-seven consecutive patients under¬
went assessment of GER by 23-hour ambu¬
latory pH monitoring.20 Esophageal acid
exposure times were compared with those
of 28 patients with histologically confirmed
esophagitis and 54 control subjects (34
asymptomatic volunteers, 20 patients with
noncardiac chest pain whose gastrointesti¬
nal tract investigations were normal). A
glass potassium chloride electrode (Radi¬
ometer) was sited 3 cm above the lower
esophageal sphincter (LES) and linked to a
meter (Synectics). Manometry
digital pH
was performed using an 8-channel catheter
(Arndorfer ESM3)2' perfused at 0.5
mL-min-1 linked through external trans¬
ducers to a chart recorder. The LES was
assessed by 3 rapid pull-throughs and a
station pull-through. Results of pH moni¬
toring were analyzed by the Mann Whitney
i/Test. Peristalsis was then studied during
a series of 15 5-mL water bolus swallows at
20-second intervals. Finally, a station pull-
 through of the upper esophageal sphincter
(TJES) was followed by a further 4 wet
Table 1.—Results of 23-Hour Ambulatory pH Monitoring*
swallows in the pharyngoesophageal seg¬ AET Upright, AET Recumbent, AET Total,
ment. Manometric data were analyzed by Median (Range, %) Median (Range, %) Median (Range, %)
unpaired Student's t test. Globus 87 5.4 (0.3-22.5) 0.2 (0-27.2) 4.2 (0.22-17.3)
Later in the study, manometric methods Asymptomatic volunteers 34 4.4 (0.9-19.6) 0.75 (0-13.3) 3.9 (0.6-16.0)
were developed to allow for UES asymme¬ Chest pain control subjects 20 2.3 (0.3-17.9) 1.5 (0-12.3) 2.5 (0.4-12.6)
try, pharyngeal sensitivity to catheter per¬ Esophagitis 28 16.5 (2.1-56.0) 12.8 (0-70.5) 17.7 (1.6-43.4)
fusion and movement, and the rapid se¬ AET indicates percentage time intra-esophageal, pH <4.
quence of events on deglutition. An addi¬
tional 48 patients with globus, 28 women
and 20 men (mean age, 50 years), and 50
asymptomatic volunteer control subjects,
22 women and 28 men (mean age, 33 years), 50-,
were studied. A 2.8-mm diameter catheter-
mounted transducer assembly (Gaeltec)
with six sensors at 60° orientation, three at
one level, was used as in the previous man¬
ometric protocol. Further study of UES
tonic pressure was performed in 31 of the 40-
patients with globus and in all control sub¬
jects with a modified sleeve catheter
(Dent)22 oriented posteriorly in the sphinc¬
ter. Both catheters were linked to a com¬
puterized waveform analysis system
(GR800, Gaeltec), which samples pressure
at 32 per second and calculates time inter¬ 30-
vals to 0.01 second. Regression analysis of
data was performed to allow for the age
V
difference between the patients and the X
control subjects.
E
RESULTS
Clinical Features and Routine Io 20-
Investigation
The globus sensation, which had
been present for less than 6 months in
50% and more than 12 months in 29%
of patients, was most often median
10-
(78%) and at the level of the larynx
(46%). Many patients had associated
symptoms, such as postnasal drip
(46%), alteration in vocal quality
(41%), heartburn more than monthly
(34%), and dysphagia (22%). Six per¬
cent of patients reported weight loss.
· — ·· —·

All patients tested had a normal com¬ Asymptomatic Chest Pain Globus Esophagitis
Control Subjects Control Subjects
plete blood cell count. Five patients (n =
34) (n =
20) (n =
87) (n =
28)
had borderline low levels of serum iron
or folate. Minor degrees of spondylitis
were present in 50% of patients, but Total esophageal acid exposure time. Medians are indicated.
prominent cervical osteophytes were
present in only three patients. Antral
mucosal thickening was noted in 15% with peptic ulcération, 5 had reflux, 2 tients (18%), but this was acute (infil¬
of patients; only two patients had an¬ had peptic ulcération alone, and 9 had trate of polymorphonuclear leuko¬
tral opacification. minor deficiency of the esophageal cytes) in only 2 patients. In 3 patients
stripping wave during recumbency. the infiltrate was focal and thought to
GER The remaining findings were minor be of little significance. Five percent of
The videorecorded upper gastro¬ pharyngeal abnormalities, mostly patients had epithelial basal cell hy¬
intestinal tract series was normal in prominent venous impressions. perplasia or elongation of the rete
69% of patients. Thirteen of 142 pa¬ Distal esophageal biopsy showed pegs. Similarly, mild chronic posterior
tients had radiological hiatus hernia, 5 some degree of inflammation in 20 pa- laryngitis was found in 18% of pa-

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 tients and interarytenoid parakerato-
Table 2.—Manometry Results*
sis in 8% of patients.
Results of prolonged pH monitoring Control Subjects Globus Patients
(Table 1) showed no significant differ¬ ( =
50) ( =
48)
ence in upright, recumbent, or total X SEM SEM
percentage time pH less than 4 be¬ Gaeltec catheter
tween patients with globus and control LES RPT 17.9 1.3 23.6
LES SPT 1.0 1.1
subjects. All three acid exposure times Peristaltic amplitude 87.1 5.2 76.7
were significantly lower in globus than
UES SPT
esophagitis patients (P < .00001). Tonic 39.6
There was no association of acid expo¬ Peak (dry swallow) 4.4 5.7
sure time with age, sex, weight, or cig¬ Wet swallow pressures
arette smoking in either patients with Pharyngeal t 36.8 2.5 73.3 7.6
UES relaxation} 7.1 0.6 1.3
globus or control subjects. UES after contractent 3.7 108.2 5.5
More detailed comparison of total
Time
esophageal acid exposure times After contraction! 2.11 1.82
showed that 23% of patients with glo¬ End of swallow} 0.17 0.14
bus had values greater than the 10% Sleeve catheter
UES maximum tonic pressure 4.5 80.1 7.7
upper limit of normal (X + 2SD) for
83.2
Wet swallow pressures
our laboratory (Figure). This was not
Pharyngeal} 21.0 1.5 37.6 3.4
reflected in a significant difference on UES after contraction 62.3 78.5 7.0
Mann Whitney U Test as the globus
*LES esophageal sphincter; RPT, rapid pull-throughs; SPT, station pull-throughs;
indicates lower and UES,
patient group also included 30 patients upper esophageal sphincter. Pressures are measured in millimeters of mercury.
below the first quintile of the control tP< .01.
distribution. %P < .0001 on regression analysis.
Of 73 patients undergoing both pH
monitoring and esophageal biopsy, 10 station pull-through measurements in UES where sphincter pressure is
had histological inflammation. Four of both groups, but there was no signifi¬ greatest. There was no sex difference
those who had total acid exposure cant difference in either parameter in any manometric parameter.
times below 10% included the three between patients and control subjects. During wet swallows recorded with
patients with only a single focus of in¬ Peristaltic amplitudes and velocities the Gaeltec catheter, however, pa¬
flammatory cells. Six of seven patients in the esophageal body were also sim¬ tients with globus showed signifi¬
with more generalized inflammation ilar in patients and control subjects. cantly greater pharyngeal and UES
also had abnormal results on pH mon¬ after-contraction pressures and more
itoring, which, therefore, showed good Motility: UES complete UES relaxation than control
correlation with histological findings. There was no significant difference subjects. Times to wet swallow after
Of the patients with an abnormal la¬ in UES tonic pressure recorded with contraction and end of UES swallow
ryngeal biopsy, evidence of reflux (ab¬ the Arndorfer catheter between pa¬ complex (measured from onset of re¬
normal total acid exposure time/ tients (70.4 ± 3.5 mm Hg) and control laxation) were also significantly re¬
esophageal biopsy/both) was found in subjects (68.9 ± 6.0 mm Hg). There duced in patients with globus on re¬
only a quarter of them. Half of the pa¬ was a trend to greater UES wet swal¬ gression analysis. There was also a
tients with histological laryngeal low after-contraction pressure in trend to greater UES peak pressure
changes were smokers. patients with globus (126.8 ± 5.6) (after dry swallows) in patients with
than control subjects (107.3 ± 8.3; globus (0.1 > > .05).
Manometry: LES and Esophageal
Body 0.1>P>.05; Student's t test) and Mean pharyngeal contraction am¬
mean pharyngeal pressure was also 8 plitude recorded from a side-hole of
The preliminary manometric mm Hg greater in patients with glo¬ the sleeve catheter was also signifi¬
studies in 87 patients with the Arn- bus. Upper esophageal sphincter find¬ cantly greater in patients with globus
dorfer catheter showed no significant ings with the Gaeltec and sleeve cath¬ than in control subjects (Table 2). The
difference between control subjects eters are listed in Table 2. There was no mean wet swallow UES after-contrac¬
and patients in LES pressure (rapid significant difference with either cath¬ tion amplitude was somewhat greater
pull-through 30.0 ± 4.5 mm Hg for
= eter in UES tonic pressure between in patients with globus, but the differ¬
control subjects; 32.6 ± 1.4 mm Hg in patients and control subjects on re¬ ence was not significant on regression
globus patients; X ± SEM). Results of gression analysis. Tonic UES pres¬ analysis.
the later manometric studies in 48 sures recorded by the sleeve catheter
were much greater than those of the
COMMENT
more patients studied with the Gaeltec
catheter are given in Table 2. Rapid Gaeltec strain gauge assembly due to This study confirms our preliminary
pull-through measurements of LES the wide-bore23 nature of the sleeve report24 that GER disease is not
pressure tended to be greater than and its orientation posteriorly in the present in the majority of patients

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with globus and, in most instances,
therefore, reflux cannot be considered
responsible for globus sensation. Pre¬
vious reports of a 60% to 90% inci¬
dence of GER in globus made the
diagnosis of reflux from radiological
studies, including acid barium exami¬
nations, now known to have a high
false-positive diagnostic rate.25 We
have used radiology, ambulatory pH
monitoring, and endoscopy and biopsy
to provide an acceptable modern ap¬
proach to the diagnosis of GER. With
these diagnostic criteria, we found ev¬
idence of reflux in 23% of patients.
A recent study of 136 patients with
globus is of interest in that it confirms
the age, sex, site, associated symp¬
toms, and low diagnostic yield of rou¬
tine investigations found in this
study.26 Despite a high incidence of
normal distal esophageal biopsy, how¬
ever, Batch26 concludes from a variety
of investigations and an uncontrolled
therapeutic trial in selected patients,
that the symptom is reflux related in
60% of cases. A pH monitoring was
performed in less than a quarter of the
patients and the upper limits of nor¬
mal described would be regarded by
some as unacceptably low.27·28 The wide
range of normal pH monitoring values
obtained from different reputable
units, each with minor differences in
technique, emphasizes the need for
each laboratory to establish its own
control values. Batch26 also placed
great reliance on the fact that fluid
(irrespective of its pH) infused at 10
mL/min into the distal esophagus re¬
produced globus sensation. This was
interpreted as evidence that impaired
esophageal clearance is causative of
the globus sensation, but an alterna¬
tive explanation is that globus was
elicited by the reflex increase in UES
pressure that follows esophageal
distention.29
In this study of consecutive patients
with globus, total esophageal acid ex¬
posure time was abnormal in 23%,
with an 18% incidence of mild esoph¬
ageal inflammation. The 5% incidence
of distal esophageal rete peg elonga¬
tion and basal cell hyperplasia is no
greater than the incidence reported in
an apparently normal population.30
Abnormalities of posterior laryngeal
biopsy were also reflux related in 25%
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of patients, but associated with ciga¬
rette smoking in 50% of patients. This
supports our previous findings on caus¬
ative factors in posterior laryngitis.31
Heartburn, occurring more than
monthly, was associated with globus in
34% of the present series. Abolition of
heartburn by antacid therapy is, how¬
ever, by no means always associated
with the relief of globus sensation.
Two uncontrolled trials in globus also
suggested a strong placebo response to
antacid therapy, as results were simi¬
lar in refluxers and nonrefluxers.1 H
We do not confirm the findings of
small studies or anecdotal reports of a
high incidence of sinusitis, osteophyte
formation, vitamin deficiency, or lin¬
gual tonsillitis in globus. Minor de¬
grees of cervical spondylitis were com¬
mon (50% ), but are equally prevalent
in the normal age-matched pop¬
ulation.32
Our study, to our knowledge, in¬
cludes the most comprehensive mano¬
metric investigation of patients with
globus to date. An early manometric
article suggested that UES hyperto-
nicity was the cause of globus
sensation,18 but other workers failed to
confirm this finding17·19·33 and the meth¬
ods used would not now be regarded as
satisfactory. Caldarelli et al33 did, how¬
ever, suggest more restricted cricopha-
ryngeal function in patients with glo¬
bus than in control subjects. We have
shown by a variety of manometric
methods that UES-resting pressure is
not elevated in patients with globus
compared with control subjects, al¬
though it is possible that UES tonic
pressure may rise transiently during
acute stress.34 Pressure measurements
in the UES are dependent on the re¬
cording system used. Thus, tonic sleeve
pressures were much greater due to
the diameter of the catheter23 and the
posterior orientation of the sleeve sen¬
sor. We have also failed to confirm
suggested manometric midesophageal
dysmotility,1719 although 6% of pa¬
tients had radiologie evidence of poor
progression of the esophageal wave.
Welin35 suggested that radiologie
slow return of the epiglottis after
deglutition might have contributed to
globus-type symptoms in the five pa¬
tients studied. Curtis and Cruess36
identified a similar abnormality in
only two patients with globus. Hannig
et al37 have suggested that high-speed
cineradiography can detect abnormal
pharyngeal motility in patients with
globus. Our results indicate that swal¬
low duration is reduced in patients
with globus who also generate higher
pharyngeal and UES after-contraction
pressures than control subjects. The
apparently greater UES relaxation in
patients with globus than in control
subjects may be an artifact caused by
greater upward displacement of the
catheter on swallowing in the former.38
The observed pharyngoesophageal
dysmotility must also be interpreted
with caution.
Although statistically significant
differences in UES after-contraction
pressures between patients with glo¬
bus and control subjects were demon¬
strated only with the strain gauge as¬
sembly, the results obtained with the
sleeve catheter point in the same di¬
rection, and the nature of the sleeve
system is such that greater damping of
the record of rapidly changing pres¬
sures is to be expected.39 Thus, for
events occurring at this frequency,
there is every reason to accept the
strain gauge assembly as providing a
more reliable record of the real pres¬
sure changes. We believe, therefore,
that the observation of a statistically
significant difference in UES after-
contraction pressure is valid, but it
does not follow that the abnormal
pharyngeal after contractions are clin¬
ically significant or are the cause of
globus sensation. The abnormal swal¬
low patterns observed may be simply a
secondary phenomenon in patients
making forceful attempts to swallow
past the 'lump,'40 particularly in view
of the wide range of local and distal
abnormalities that have long been as¬
sociated with globus. Nonetheless, the
abnormalities are present in the area
where the globus symptom occurs and
it is possible that pharyngoesophageal
dysmotility contributes to the genera¬
tion of globus, probably not as an iso¬
lated causative factor, but perhaps in
association with other factors. These
may be physical stimuli, such as re¬
flux, or postnasal drip or may be psy¬
chological factors such as those that
we have previously demonstrated in
female patients with globus. Female,
 but not male, patients with globus
have introverted personalities.41 Fe¬
male patients with globus do not show
hysteroid traits, but they have an in¬
creased incidence of occult psychiatric
morbidity compared with ear, nose,
and throat control subjects, and show
increased levels of depression, anxiety,
and somatic concern when tested by
the Crown Crisp Experiential Index.42
1. Moloy PJ, Charter R. The globus symptom.
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744.
2. Nishijima W, Takoda S, Hasegawa M. Occult
gastrointestinal tract lesions associated with the
globus syndrome. Arch Otolaryngol Head Neck
Surg. 1984;110:246-247.
3. Wilson JA, Murray JAM, Von Haacke NP.
Rigid endoscopy in ENT practice. J Laryngol Otol.
1987;101:286-292.
4. Maran AG, Jacobson I. Cervical osteophytes
presenting with pharyngeal symptoms. Laryngo-
scope. 1971;81:412-417.
5. Mills CP. A 'lump' in the throat. J Laryngol
Otol. 1956;70:530-534.
6. Tremble GE. Hypertrophied lingual tonsils.
Laryngoscope. 1956;67:785-795.
7. Campbell J. Facial paraesthesia accompany-
ing facial pain. Br Dental J. 1962;112:108-113.
8. Miyake H, Matsuzaki H. Studies on abnor-
mal feeling in the throat. Pract Otorhinolaryngol.
1970;32:364-372.
9. Von Steinmann EP. Globus Pharyngis und
Hiatus Hernia. Schweiz Med Wochenschr. 1961;
10:304-306.
10. Malcolmson KG. Radiological findings in
globus hystericus. Br J Radiol. 1966;39:583-586.
11. Malcomson KG. Globus hystericus vel
pharyngis. J Laryngol Otol. 1968;82:219-230.
12. Delahunty JE, Ardran GM. Globus hysteri-
cus: a manifestation of reflux oesophagitis?
J Laryngol Otol. 1970;84:1049-1054.
13. Cherry J, Siegel CI, Margulies SI, Donner
M. Pharyngeal localisation of symptoms of gas-
troesophageal reflux. Ann Otol Rhinol Laryngol.
1970;79:912-914.
14. Mair IWS, Schroder KE, Modalsli B, Mau-
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tom. J Laryngol Otol. 1974;88:1033-1054.
15. Freeland AP, Ardran GM, Emrys-Roberts
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J Laryngol Otol. 1974;88:1025-1031.
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All of the wide range of minor phys¬
ical abnormalities that can be identi¬
fied in patients with globus frequently
exist in the absence of globus sensa¬
tion. Our findings of an abnormal swal¬
low pattern, and of psychological ab¬
normalities, such as introversion and
increased somatic concern in females
with globus, lead us to believe that fu¬
ture research should be directed to the
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