Background: Globus is a feeling of a sensation of a lump in the throat. A variety of explanations (physical and psychological) have been proposed in its etiology, but it is nonspecific nature and high incidence makes a causative association hard to establish or refute.
Objective: To associate the role of Anxiety in the etiology of globus pharyngeus.
Materials and Methods: A prospective study was conducted in a rural private hospital in South India. One hundred and ninety-three patients with a sensation of lump in the throat were assessed after obtaining consent. A strict inclusion and exclusion criteria meant only 54 made it to the final study. A pan endoscopy was conducted to rule out local lesions. In each patient with absence of a local lesion, Hamilton-A Anxiety (HAM-A) Scale was issued for the levels of anxiety (values between 0 and 56) and the visual analog scale (VAS) for uneasiness experienced (values between 1 and 10) before and after 12-weeks treatment. Management included oral escitalopram and clonazepam.
Results: At the end of the study, the average score for HAM-A Scale was 13.96 compared to 26.17 before treatment, an improvement of 46.65%. The average values before and after treatment in the VAS before and after treatment were 7.43 and 3.33, an improvement of 55.18%.
Conclusion: In the absence of a local cause, the diagnosis of globus should be looked at from psychological viewpoints. Undiagnosed or untreated anxiety can cause globus and it is more commonly seen in women in the age group of 36–45 years. The P value was significant in this study where we treated anxiety leading to globus (<0.05). Thus, we infer that treatment of anxiety as an entity can help in the management of globus.
Keywords: Anxiety, clonazepam, escitalopram, globus, Hamilton-A Anxiety Scale
| Introduction|| |
Globus is defined as a continuous or intermittent nonpainful sensation of a significant lump in the throat. It is long lasting, difficult to treat, seen often in any select group of individuals with a large tendency for recurrence. The etiology is confusing and there has been plenty of disagreement about how the management protocol should be devised effectively for a good clinical improvement. Historically, globus was considered a psychological problem. Currently, it is obvious that the causes are plenty, although some patients' symptoms may have a psychological background. Laryngopharyngeal reflux (LPR), gastroesophageal reflux disease (GERD), esophageal motor causes, and abnormal upper esophageal sphincter function are suggested to cause globus pharyngeus. However, studies demonstrating the relationship between these and globus are mainly not accurate to base a conclusion on the same., The incidence of globus constitutes about 4% of all referrals seen in the Department of otorhinolaryngology and head–and-neck surgery.
The Hamilton-A Anxiety (HAM-A) Scale was one of the first rating scales developed to quantitatively measure the severity of the basic symptoms and signs of anxiety. Since the scale is easy to administer and use, it can be used to assess the status of patients with anxiety-related symptoms in a noninvasive manner.
It has been extensively studied and proved that globus patients have more stress and severe life events throughout the year compared to controls. Globus patients have commonly felt more symptoms when a highly emotional state occurred in their life. It must thus be noted that anxiety and psychological causes can cause somatic system disorders and can have a large role to play in the diagnosis and management of globus when no local cause of inflammation/infection is identified.
Escitalopram is a commonly used drug belonging to the class of selective serotonin reuptake inhibitors (SSRIs). It is mainly used to treat major depressive disorder or generalized anxiety disorder and can be taken orally. Clonazepam is a benzodiazepine which can be used as an anxiolytic and can be used as an adjunct with other drugs.
The aim of this study conducted in RVM Institute of Medical Sciences and Hospital was to find an association of the levels of stress/anxiety/psychological causes in patients with globus who otherwise do not have any local causes for their symptomatology. Furthermore, the usefulness of HAM-A in diagnosing levels of anxiety and linking the values with clinical symptoms has been taken up.
| Materials and Methods|| |
All patients presenting to the department of otorhinolaryngology and head-and-neck surgery and to the department of psychiatry in a hospital in South India between June 2019 and May 2021 with symptoms of lump in throat/irritation in throat/difficulty in swallowing/voice change were taken to be part of the study after obtaining written and informed consent. The institute's ethical committee approval was taken before commencement of the study (viz. Reference No. 1033/21).
The inclusion criteria were individuals in the age group of 18–60 years, symptoms of lump in throat, consenting and willing for a 12-week follow-up, and established psychological basis for globus on clinical evaluation and study.
The exclusion criteria were patients with local causes for Globus, GERD and LPR, previous diagnosis of other psychiatric illness not associated with the present scenario, and history of diabetes mellitus as the benzodiazepines can mask hypoglycemic symptoms.
One hundred and ninety-three patients were found to have globus pharyngeus in the aforementioned study period. Out of this, 139 had a local cause for globus (i.e. 45 had GERD with or without esophagitis, 29 had LPR with or without laryngeal mucosal lesions, 12 had acute laryngitis, 9 had asthma, 16 had some form of tumor, and 28 had chronic tonsillitis) and were thus not taken to be part of the study. The remaining 54 were included in the study. To avoid measurement bias, the scale was noted down by the same practitioner at all times.
All the patients underwent a pan endoscopy first to rule out all local causes in the nose, nasopharynx, oral cavity, oropharynx, hypopharynx, larynx, and esophagus. In the absence of a local cause, all patients were interviewed by the same psychiatrist to take a complete history in view of underlying psychological cause. They were then asked to fill up the HAM-A [Figure 1]. Scale before the beginning of the treatment where each item is scored on a scale of 0 (not present) to 4 (severe), with a total score range of 0–56, where <17 indicates mild severity, 18–24 mild to moderate severity, and 25–30 moderate to severe. This scale is reliable as it has a good Cronbach's alpha rating (0.893). He scale was translated to the local language in cases and read out to the patient when in need for better understanding. This procedure was done by the same practitioner to avoid observer bias. The scale was not issued to the patient for them to fill themselves.
A visual analog scale (VAS) from 1 to 10 with was also issued before treatment to describe the level of pain faced by the patient. Each patient was asked to rate their pain scores based on what they feel (1 being the lowest and 10 being the highest).
The treatment was then started for the consenting individuals. Since the case group was very specific, multimodality treatment was administered. Tablet escitalopram 20 mg was given after breakfast for 12 weeks and tablet clonazepam 0.5 mg after dinner for 3 weeks tapered to 0.25 mg for 1 week (total of 4 weeks). As the SSRIs usually increase the levels of anxiety upon initial administration and take 3–4 weeks for proper pharmacological effects, a benzodiazepine was given to control this change. Along with all this, proper psychotherapy was given to every patient by the same psychiatrist to avoid bias. The drugs have universally good compliant nature and have been used regularly for the past 3 decades.
At the end of 12 weeks, the same scales were again administered to the patients and values were recorded. A statistical comparison was then performed between the results obtained.
The HAM-A scale is allowed to be used universally as it is a standard scale. None of our patients had any side effects as the medicines were given only with a doctor's consultation. There was no selection bias since we had no grouping or randomization.
All statistics were performed using the SPSS Statistics 19 for Windows (IBM Corp., Armonk, NY, USA). Samples were compared by a paired t-test. P < 0.05 was considered statistically significant. The confidence interval was set at 95%.
| Observations and Results|| |
A total of 54 patients were part of our study with 43 females and 11 males. The most common age group was found to be 36–45 years [Figure 2] and [Figure 3].
At the end of the 12-week time interval, the average score for HAM-A scale was 13.96 compared to 26.17 before the commencement of treatment. The improvement was found to be 46.65% [Table 1]. The average values before and after treatment in the VAS before and after treatment were 7.43 and 3.33, an improvement of 55.18% [Table 2]. A linear improvement was seen in both the scales when studied side by side.
|Table 1: Paired samples correlations and statistics before and after treatment for the Hamilton A Scale|
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|Table 2: Paired samples correlations and statistics before and after treatment for visual analog scale|
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Clinically, 48 of the 54 patients had a significant improvement in the feeling of globus, while the rest 6 patients had mild improvement in the symptom. 54 out of the 193 patients (27.97%) had no local cause of globus, i.e., they had the symptoms because of anxiety; which makes it a significant causative agent.
| Discussion|| |
The sensation of globus is a common condition in all socioeconomic groups and has a multifaceted etiology. There has been a lot of discussion and investigation done to identify the age-group which has the most incidence of globus. A study conducted by Ali and Wilson in 2007 stated that the presence of globus had no significant association with age, while another study conducted by Drossman and Li in 1993 stated that it peaked in the middle age group. As there is no clear cut consistent etiology for the same, management strategies have been altered significantly over the course of time, and at present, the treatment is solely based on symptomatic relief and prevention of recurrence.
Studies have suggested that GERD and LPR can be major causes of globus., Thus, antireflux medication becomes the most important treatment for these cases. Since the etiology is multifaceted, a single treatment modality would more often than not result in poor results. Therefore, other established treatment options such as speech and language therapy, antidepressants, and cognitive-behavioral therapy have been considered.,,
In our study, escitalopram (SSRI) was given for a period of 12 weeks. Since this causes serotonin to be available in the synaptic cleft for a longer duration, the general symptom of anxiety is reduced. Clonazepam acts on the gamma aminobutyric acid – a receptor and enhances its inhibitory neurotransmission function, thereby achieving a sense of calm. This has been the standard method of management for the past 20 years over a large population and has seen no side effects.
Some studies have shown that antidepressants help in improving the symptom of globus. In patients with no organic local cause, this method of management can become a cornerstone in the management of globus.
Statistical analysis of one such particular study with multiple linear regression analysis showed a positive relationship between the improvement of VAS in the group without esophagitis when patients were stratified with the presence of comorbid esophagitis. These results suggested the possible association between globus sensation and anxiety in the patients without comorbid esophagitis.
Analyzing patient history carefully may reveal an associated voice problem, stress, or tension in the neck. The management should focus on these issues as a first-line problem. Most of the patients suffer from mild and intermittent globus symptoms and may alleviate without any form of treatment. The most important thing is to explain the patient the symptom's natural course and advise to contact again if the symptoms become severe or progressive, or if other symptoms such as pain or dysphagia occur.
Our study was essentially based on patients having globus without a local cause and a proper evaluation and diagnosis of anxiety based on extensive history taking and clinical assessment. Due to lack of studies in this particular scenario, there needed to be light thrown on the recurring topic of “anxiety-induced globus.” We encountered a subjective bias in the study which was addressed. We made sure that the scale was read out only once and by the same investigator to all participants. No potential outcomes/directions were expected in the study before commencement.
The HAM-A Scale and the VAS have been used extensively over the years for various studies. Since they are easy to use and inexpensive, they were chosen for our study. The application is simple and can be done multiple times too for accurate results.
The limitations of the study are that it might have poor external validity as the study was performed in one center among a specific group of individuals.
| Conclusion|| |
In the absence of a local cause, the diagnosis of globus should be looked at from psychological viewpoints. Undiagnosed or untreated anxiety can cause globus and it is more commonly seen in women in the age group of 36–45 years. We found that about 28% of our patients had globus secondary to anxiety. Increased understanding of this diagnosis, biopsychosocial approaches, and liaison among otorhinolaryngologists and psychiatrists will be useful and highly beneficial in the early diagnosis and management of this complicated disorder. The HAM-A scale and VAS can be used easily as they are inexpensive and easy to procure. The P value in our study was found to be <0.05 in both the scales used. Thus, we infer that treatment of anxiety can directly improve the symptoms of globus.
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Conflicts of interest
There are no conflicts of interest.
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Saai Ram Thejas,
Department of Otorhinolaryngology, RVM Institute of Medical Sciences, Siddipet - 502 279, Telangana
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]