Swallowing Expert Says Globus Should Be Treated
From Clinical Update, Fall 2006
Patients come in and say, ‘This is scary, you don’t know how scary this is.’”
Susan G. Butler, PhD, an associate professor of surgical sciences-otolaryngology at Wake Forest Baptist Medical Center was describing a condition that some physicians tend to write off as not serious enough even to treat. The condition is what doctors commonly call “globus,” and patients call a “lump in the throat.”
Butler said doctors tend to dismiss globus as something relatively minor that will take care of itself. But, the patient is suffering a lot of discomfort, it is potentially a very dangerous condition, and there is no need for the condition to persist as it can often be treated successfully, she said.
Butler, a swallowing expert in Wake Forest Baptist’s Center for Voice and Swallowing Disorders, said globus is frequently caused by stomach reflux in the upper esophagus, which in turn causes the upper esophageal sphincter (UES) muscle, or cricopharyngeal muscle, to go into spasm, which can cause the sensation of something stuck in the throat.
Food can actually stick in the throat because of the spasm. “When they try to swallow, the cricopharyngeus/UES will not relax to let a big bolus or a big piece of food go into the esophagus. They can have solid food right above their airway. And some of those patients have had situations where they’ve needed the Heimlich maneuver to cough out a pill or piece of meat out of their airway,” she said.
A first step in diagnosis and treatment of globus is to test for reflux in the throat. If the reflux is under control but the sensation of globus persists, Butler performs simultaneous manometry and flexible endoscopic evaluation of swallowing (manovideoendoscopy). She uses a tiny manometric catheter to check for elevated pressure in the UES, indicating a spasm in the cricopharyngeus. At the same time of the manometric evaluation, the flexible endoscopic evaluation of swallowing (FEES) assesses bolus flow through the pharynx. “Often when elevated UES resting pressures are identified, FEES identifies solid food that sticks in the pharynx,” Butler said.
“Elevated UES pressures as measured manometrically indicate UES dilatation and/or BOTOX®. We have had a lot of success with those procedures.”
BOTOX can be injected in a short surgical procedure done by S. Carter Wright, MD, assistant professor of surgical sciences-otolaryngology. “It just weakens or paralyzes that sphincter so that the sensation of globus can be alleviated,” said Butler.
The key, however, is the manometric study. If the patient does not have elevated UES pressures, BOTOX may have no effect because the globus is being caused by something else.
“Currently the Center for Voice and Swallowing disorders is the only clinical lab in the country offering this simultaneous manometric and FEES exam, which can illuminate the likely etiology of and problems associated with globus. It is a quantitative assessment and truly guiding how we are treating patients,” Butler said.
“So if a doctor has a patient who mentions, ‘I have something stuck in my throat,’ there is probably a physiologic reason, which we may have treatment for.”