Globus Sensation And Retching In A 21-year-old Male Football Player.

Abstract

HISTORY: 21 year old male football player presents with a tightness in his throat and dry heaving during football activity. He had similar symptoms 4 years ago that resurfaced 5 months ago without inciting event. Symptoms occur with strenuous activity on the field and cause a sensation of throat tightness that makes him want to vomit. He immediately loses focus on the game when symptoms occur, negatively affecting his performance. Denies stridor, dysphagia, dysphonia, unsteady gait, history of psychological disorder or treatment. PHYSICAL EXAM: GEN: NAD, well-appearing. HEENT: Oropharynx clear, normal tongue protrusion and palate elevation. Neck: No lymphadenopathy, no thyromegaly. CV: RRR, no murmur. Lungs: CTAB.GI: Normal bowel sounds, nontender. NEURO: No focal deficits, CN II-XII grossly intact. PSYCH: Appropriate mood and affect. Appropriate insight and judgment. DIFFERENTIAL DIAGNOSIS: 1. GERD 2. Vocal cord dysfunction 3. Esophageal spasm 4. Exercise-induced bronchospasm 5. Anxiety disorder TEST AND RESULTS: Barium swallow study: Small transient sliding hiatal hernia. Laryngoscopy with stroboscopy: Mild edema of bilateral vocal cords. Normal vocal fold mobility and morphology bilaterally. Exercise bike test with fiberoptic laryngoscopy: No paradoxical motion of vocal cords at rest or with bike testing. No evidence of vocal cord dysfunction. Esophageal manometry: Normal manometry but ineffective esophageal motility with viscous/solid consistencies indicating minor disorder of esophageal motility not classifiable. FINAL/WORKING DIAGNOSIS: Mild esophageal spasm complicated by unspecified anxiety disorder. TREATMENT AND OUTCOMES: He was started on empiric PPI therapy, which was discontinued after one week given no response. He was referred to a sports psychologist and engaged in cognitive behavioral therapy including psychoeducation, cognitive restructuring, exposure therapy, and mindfulness training to assist with reduction of his physiological symptoms. He practiced swallowing exposures during physical exertion over 3 weeks. Following exposure therapy, he reported being able to distract himself and reduce his concern about the sensation. He had significant improvement in his symptoms and finished the season at a highly competitive level without any recurrence of episodes.