Two Cases of Globus

Globus 1

A man in his mid thirties claimed he repeatedly had food stick in his esophagus. It started ten years earlier when he took a big handful of vitamins at one time and he couldn’t get them to go down. He had to force them out by sticking his fingers down his throat, causing him to forcibly vomit. He had experienced many such episodes since then and said it could happen with eating something as simple as a poorly chewed almond.

People with abnormal narrowing of the esophagus may have problems like this. However, this guy had been told his esophagus was normal on a recent x-ray swallowing study.

After hearing this history, I felt pretty sure he did not have a physical problem. As I watched him, this impression was reinforced. He appeared nervous, uptight, and very weird. He gave in-depth, detailed descriptions of all his symptoms. When I was talking, he would stare off into space with an anxious look on his face, holding his hand on his chest. Lost in his own thoughts and concerns, he would then interrupt me to add some new detail of his condition. He would get up mid-sentence, whether his or mine, go to the sink, stick his fingers down his throat causing himself to bring up a small amount of saliva which he would point at and say, “See!”

He paid such little attention to my explanations that, had it not been so fascinating, I would have been annoyed. Finely, I had to be blunt. “We are sending you home now. I just need to know if you want me to refer you to a doctor here or if you are going to see your doctor in the city where you live.” I had to ask him several times before he gave an answer rather than just repeating things he had already said or going to the sink and pushing fingers down his throat.

Globus 2

A middle-aged man came in by ambulance after almost choking to death on his saliva while driving. He said he was saved only after he managed to get a Hall’s cough drop in his mouth. The menthol vapors allegedly opened his chronically congested nasal passages so he could better breathe through his nose, saving him from certain death.

He had a long history of ankylosing spondylitis* which caused fusion of his entire spine so he was not able to bend or rotate his trunk or neck. He also had a long history of unexplained weight loss.

For a year, he had trouble breathing out of his nose. He also had recurrent choking on thick saliva. Unfortunately, no doctor had been able to explain this or offer any beneficial treatment.

My immediate impression was the guy was crazy. He looked distracted when I was talking. Looking down, he plugged one nostril with a thumb, took a little sniff to see if it were open and then repeated the same with the other side of his nose. This he repeated several times during our interview.

I’ve been saved many times in emergency medicine by stopping to ask if my impressions are wrong or if I might be missing something. My impression was that this was all in his head but I forced myself to re-examine my perceptions in this situation. The patient was very skinny. His stiff spine and abnormally stooped posture gave him a creepy appearance and caused him to move in a strange way. Could he also have something that might cause him to choke to death?

I excused myself and went to the computer to look closer at his medical record. I confirmed the history he gave me. A recent CT scan showed normal airway anatomy and a swallowing study showed no abnormality. He also had an unremarkable evaluation by an ENT specialist. This supported my impression he was suffering from a mental and not a physical problem. The only other thing I needed to know was if he could swallow or not.

I got a cup of water and took it to him. He said he was unable to swallow because his saliva was too thick. I told him to drink anyway.

He hesitatingly took the cup and pressed it to his lips. A slight amount of water entered his mouth.

“Good. Drink some more.”

This time he actually took a small sip.

“Drink it all.”

And he did. With no problem.

I tried to help him see that his perceptions were not logical and had no basis in anatomy or medicine.  I did this in a gentle and understanding but straightforward way. He would accept no reassurance nor reconsider his impressions that he was at risk of dying from nasal congestion and choking on thick saliva. He was truly afraid if he went home he would die. As he begged to stay, the poor man painted such a miserable picture, I was unable to kick him out.

For the rest of the night, he slept on a gurney in the hallway. A couple of times, he got up to tell me “it” was happening. He would demonstrate “it” by sticking out his long, snaky tongue covered with saliva he had collected in his mouth. I would get him another drink of water and he would go back to his bed.

In the morning, he left with plans to drink water, take Hall’s as needed and follow up with his doctors.

Take a look at http://en.wikipedia.org/wiki/Globus_pharyngis which points out that people get this sort of thing and it is all in their brain. A broader Google search was also interesting to me.

* http://en.wikipedia.org/wiki/Ankylosing_spondylitis